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Wood, Ralph
ac3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit '' Name First Middle Last Sex FA LP!} VrnAUL)L(I& LOo o 0 mflLE Date of Death Age If Veteran of U.S. Armed Fo s, A'y ) 13 War or Dates Ro(ZE R 19 sa- - N SS- 1, Place of th Hospital, Institution or City, nrn er Village- IDS #ILLS Street Address Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending J� Circumstances Investigation at Medical Certifier Name Title Q 11}A L 1 cA ) -Avv\A L -'N\___S) Address 100 '1 --1: G,E,10S LLS, -T1 1 - `-O 1 iRiii Death Certificate Filed ) District Number Register Number City, Town-er Village C-f-CEtq -VALLS S7 O f . .Da_ ❑Burial Date / ,,,,/ Crematory .G7El Entombment ) � o U i LJ C�.REt'Y\HT�(zt uwv Address ►f remation CR E(R, tl E�NSC�t.tl � 1f\ a$O�' Date ace Removed 3❑Removal and/or Held and/or F,, Address UY Hold 0 Date Point of rii Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number ii Name of Funeral Home - -t s,N3F*L t rnE,) 1 N c, ©1 n In Address , G c10 O c i LAKE of_ c) \ 1 a.. 45' Name of Funeral Firm Making Disposition onto Whom Remains are Shipped, If Other than Above 2 Address IX ILI Permission is hereby granted to dispose of the human -mains described a ove as ind.cate . pligl Date Issued 6v, / . Q 6 Registrar of Vital Statistics / . -., d>--C _ (signature) District Number 6-60 / Place 7,CG=j[„4 I certify that the remains of the decedent identified a e w- • disposed of in accordance with this permit on: ILI Date of Disposition 6/S `V h Place of Disposition Ditl a vi eh.) (rr.n,S'ro r1 a. a (address) It1 U) CC (section) /, (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises 4- h r' S 5Q rl41 Pr �Q^ (please print) I Signature £AVl� ii•vt-Ler. Title Cf l'mV ( (over) DOH-1555 (02/2004)