Dubret, Louis NEW YORK STATE DEPARTMENT OF HEALTH 5-1)
Vital Records Section L Burial - Transit Permit
11 Name First i J ) Middle Last
iiiiiiiiil L-00 i S (1014-?...10/1 . ti 13 6 la 6-7— /9702,/.7'
mi Date of Death Age If Veteran of U.S. Armed Forces,
<': / //l In D [., cp./ft,j War or Dates / 9 Y3 -) '/ Jr`Place o .eath F�ospital. stitution or
City} own b'Village le tab [� L>7u� Street Addre `` , J JL,,4e✓i..eik.S,(, / ;
Manner o DeathrNatural Cause Ac ids nt Homicide Suicide Undetermined Pending
Circumstances Investigation
ii Medical Certifier Name —7-- /� Title ,(��
Address ,1 0 E M 1---, el-65kii 1-191,1_,_f(� ifr WI Li
Deat icate Filed tact Number sier Number
<� Cit Town Village C/N) U ~t lg t COS
Date emeteryCremato
��� U�" ❑Burial /j /7 6 //O1� /61-3
Address
:::1►-. Cremation v- o„._ 1243, C U '�,•raII 0174-
,f Z' /2 y
Date Place Removed
0❑Removal• and/or Held
2 and/or Address
Hold
Qfv: Date Point of
N Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Iii Permit Issued to // Registration Number
>: Name of Funeral Home x:,1'2i1 )), �} K F,.,a, , ) ive.;- o i/9 y
Address /
/ c
// t_,,'F 6--T(' `J i 0 o .oc I5 U ay Ay 12.,pc i.
:....
: Name of Funeral Fi Making Disposition or to Whom
Pe Remains are Shipped, If Other than Abov
e
Address
JAI
)
ill Permission is hereby granted to dispose of the human remains described above as indicated.
iiiiii Date Issued 11 l I Co 4 O(n Registrar of Vital Statistics c::k .C S/ �
(signature)
District NumbeiCLe
Place c--R---r-N, (:)-1 a LLS .-r�S1v'
I certify that the remains of the decedent identified above were disposed of in accor ante with this permit on:
WDate of Disposition i 4 /.I CAC, Place of Disposition P,n by w "I'r,4 Liri 4++.
2 (address)
Ui
Cl) (section) i (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises C r i t S-{nnL0
(please print)
.4! Signature `./ts,.. /1:k Title cisIrn-atri r
(over)
DOH-1555 (9/98)