Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Van Horne, Norvan
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle L st Sex�t,� O/ �>A V /LJL>' Date of Deat Z 2- A e9 If Veteran of U.S. Armed Forces, / War or Dates G`1 — y 2 s j- P P . e of Death / Hospital, Institution or dopown or Village GL6s',�)S Fes, c Street Address ‘A z , /Ff6?9"L c , CI ' -nner of DeathIKNatural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending U./ Circumstances Investigation tu Medical Certifier Name Title Address D •th Certificate Filed District Number Register Number City own or Village QL,(:5',,-i S FiyL�,& 5 6 o ) 6 -2-5 0-Burial Date Cemetery o f remso atory Entombment /L J/3 76 6 / r,Je V/G�-J Address ( -. (Cremation ej .) .&‘,•— s Q Ai � 0 06-L-,Date Place Removed t ❑ Removal and/or Held ► and/or Address Hold 0 Date Point of ❑Transportation Shipment f by Common Destination Carrier Q Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to _ &WC— Registration Number Name of Funeral Home ,v, yz I/ \ &- / u1JL C)/! 9 y Address 6i----ris24--•// '�, 0 U 13 UYL-c , ,,A.�' , /2Name of Funeral FirmDisposition or to Whom Remains are Shipped, than Above • Address IX '7.1 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued / 2,/ i 3 ) 0 6 Registrar of Vital Statistics 1423. ,a...-4-A c-t.c.�` a f i..i (signature) District Number 5 e,© ) Place 6 .5zMS ct \\5 1 NA-? I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ill• Date of Disposition i.//iy Al, Place of Disposition (l,n.Qv.'i,. (rW,it(Jr; v yi. (address) W CCU) (section) (lot number) (grave number) Ct Name of Sexton or Person in Charge of Premises CI, r, s Seon e( 2 /� (please print) Signature iLi / 2.M'c" Title 1. " kt`r (over) DOH-1555 (02/2004)