Dillon, Matthew NEW YORK STATE DEPARTMENT OF HEALTH rtf ' 'ir' 1 I
Vital Records Section Burial - Transit Permit
of Name First Middle st Sex
>, ,hl -1 f.hf + r /I k
iiiiiii Date of;De th ;Pge f rr ,,r If Veteran of U S;Ar ec.Forpes,,
Q4, : d4, ,,c ,. £� ,. ,,,War or.Dates ,., .,l� „,- .•,vlf+ t,
FPlace of eath _ Hospital, Institution or
City, Town.or Village, ( `TP r j , iti,, : Street Address, U :,,/72jn,' • a r^ 1
IMlaraner of,Death va atural Cause El A cident 1 .Homicide 4JSuicide .;. 1 Undetermined, , Rending
,.t ;Circumstances .1.1771 Investigation
al Medical Certifier Name Title
6, 1-A Vic;`3 LJA r M ,,
,,� Address ,, ,.I ,
{ Goo . ee WO' AAea� r/Aciri A `a 7y
Iiii Dea . II- icate Filed ''�` .•- ,District Nu b_gr. Register,Number
k. :City Village tN' ..t QQ �: /. ��," ,,
Date ,,, . ,. 7 Ce tery or Crematory-
❑Burial C) lv / 6 �06 Ale dieiti e2)-64-7,► <a7
Address -Q , !.. - - . .. , , , . , ,- .,
®-Cremation i9Q..ex'S v r-y ")-2'
Date l Place Removed
0 Removal and/or Held
and/or Address
;L.F Hold
46 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to /�` � Registration Number
3 Name of FuneralHome 24/3y4 e, / �U�e ypj e- 0c7.3
t
Address C.t hi,,rJ h A /.2, , f a-�`�d
,...._,:::,!„,. Name of Funeral Firm Making Disposition or to Whom
—. Remains are Shipped, If Other than Above
Address
'U
A
Permission is hereby granted to dispose of the hum-n ref. s describe• a• •v a -nd. t d.
ii:i:i Date Issued Ct6%3/o'toei Registrar of Vital Statis �f���C�st / 3
(signature)
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District Number/5-6�J rlace W�%S�o r l y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
EDate of Disposition -- i4- Place of Disposition . - N4- j'. ni ? (a.r 1 ,i. .i-#�` ' L' --1,^\_:
(address)
Lu
()
III (section) ..(lot number) (grave number)
GY ;Name of Sexton or Person in Charge of Premises \1 - ? ,./
z (please print)
W Signature �/ <x'�� 7 e=r`",_ Title - i ire k '% t `'
► _ t
(over)
DOH-1555 (9/98)