Duell, Donald NEW YORK STATE DEPARTMENT OF HEALTH , 93-2
Vital Records Section - Burial - Transit Permit
• Name First')
Mi dte Last) az-2,4_ I Sex
Date of Death/ Age If Veteran of U.S. Armed Forces,
l 0 /!O (-P P- War or Dates / /y 3 —J 9 y 6
Place . Beath
Hospital, Institution or _ h-r-
a
Ci Town'r Village t JZ Ns d tS1�^ Street Ad��re 6 S O ,rb`NS•g -Manner of Death Natural Cause 0 ci ent Q Homicide 0 Suicide ❑Undetermined❑Pending
Circumstances Investigation
mj Medical Certifier Name Title
Address
Oil' Deat Lentikcate tiled tI>u Distneh Rrgister dumber
€': Ci , Town' Village j l
Date Cemetery or remato
❑Burial /0 /2- d LP / i,j j lJ/fsi-J
Address •
:.:.:Cremation G O „_,,_ 4,, , & Off:- a
2 Date Place Removed
0❑Removal and/or Held
-, and/or Address
Hold(i)
Hold
0 Date Point of
at❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to y _ Registration Number
12 Name of Funeral Home 1/ ,r;, ,N , R fl& J-u�,L-r ANC" 011911
>< Address /
If (rar &—r 5- '-r. 0o ac[sU- t / r 12. stf
<` Name of Funeral Film Making Disposition or to Whom •
Remains are Shipped. If Other than Above
Address
i
< Permission is hereby granted to dispose of the human re ains described abovg..as indicated.
til Date Issued tO/c-'/Qu p Registrar of Vital Statistics • . U r,��
/ __ ((signature)
.:,
»` District Numbera fl Place ) rD t....1-,-, a'T � i 9�-�,
I certify that the remains of the decedent identified above were disposed of in cordanc with this permit on:
F
Z Date of Disposition i o/3 io 1. Place of Disposition P1 nv -t w rip...,s yr, v
I (address)
WI
iT (section) (lo umber) (grave number)
0 Name of Sexton or Person in Charge of Premises L r,s nG ¶
z (please print)
�'ln--41 Signature i1 Title C'.-e w►c_"k:.J
(over)
DOH-1555 (9/98)