Shattuck, Timothy NEW YORK STATE DEPARTMENT OF HEALTH _% t I
Vital Records Section Burial - Transit Permit
Hil Name First__--- Middli! `��^^/A B t Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
rDe4 7 P ) 4- (- War or Dates i(gv — 10
Place of Death Hospital, Institution or `-�
City wn o Village d r /K ✓4 Lµ ze,A Street Address a o coC C i i —
j, Manner of Death❑Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
fil Medical Certifier Name Title
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Address n�
7 7 f" et,A 5)+. v AttcAS ,, fqr I2t t ."—
iiiiiDeat i ate Filed /, / District'Number _ 'J" Register Number
City, oratn..e Village DI `-'\J4 LKL-e f'�-z S( S 6
Date I Cemetery or rematory
❑Burial I), / ti /0 G �nev;c,... (__re v.1'1-d r.:—t..
Address /1
Cremation C,5 .�e._e.t s 4 cm- f
Date t Place Removed
2 1-10❑Removal and/or Held
and/or Address
Hold
CO
Q Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
. < Permit Issued to S / Registration Number
Name of Funeral Home C� �h -c t,tom, �� c 3
AddressSate f-, ..- ,{
Lip Name of Funeral Firm Making Disposition or to Whom / t
Remains are Shipped, If Other than Above
ke Address
CC
rgt
iiiil Permission is hereby granted to dispose of the human .c<9
ains//dde�escribed ' ove as ir.d cat .
it Date Issuedcee., ' , 76 Registrar of Vital Statistics LQJ e= P /32-0
lo4gnature)
iN District Number 6-6 6 Place L "."?..---/--e----
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
E Date of Disposition ca /tl/€b Place of Disposition PinQtAPw (c rt C.f I t,,.r.‘
2 (address)
LU
U3
CC (section) ( ,{iot number) (grave number)
0 Name of Sexton or Person in Charge of Premises (h r,s J e rv, e(*
z .,-)4, (please print) ,
U: Signature L i/j u;, ��( ,.�„�,tr— Title ere c fc i'
(over)
DOH-1555 (9/98)