Smith, Milford NEW YORK STATE DEPARTMENT OF HEATH
Vital Records Section N Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
Hil f , i 1, 2c>G6' e Z War or Dates
Ni
}4, Place 940 eath / Hospital, Institution or / /
City, ow or Village G�4 o-t ///e 1 Street Address 7t C2�4.6.1/GC l-ve5//4-5' /4-_-�
I. Manner of Death Jatural Cause Accident Homicide Suicide Undetermined Pending
1 Circumstances Investigation
Medical Certifier Name Title
4r-&iey �„..:_,tvs4e,,'A✓ 4 .
ill ill /�
Addressd c •
3 S C''//J c.!"' S/ , /'fIK,J.-- ,,�f e ./.
iiiig DeathS4Vicate Filed ,/ District Number Register Number
Cit wn�r Village Ere'-,vvr (((
Date Cemetery or Crematory)
❑Burial 4, z/ Lue2(,, ,//r,ee/ G / '
Address
Cremation /`
Date Place Removed
0 Removal and/or Held
r and/or Address
az Hold
p Date Point of
It ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ffl Permit Issued to Registration Number
iiiiiiiiii Name of Funeral Home Pc,4 t:r-j- ie-(. ;a. v,Le ,d./ /{u*,,,,r- (7 /_5-7 3
Address ia
2-,3 C- �cr',"-c: 4 57. 6.�.9:11 i-,-, il,,,,
Liiiiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
ix
€ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued c", )3,( ' _ , Registrar of Vital Statistics )
iE ignature)
ni District Number 51SC.p Place 6-Cctrv; I1 , NI
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
'f-
p
6 Date of Disposition .2'2 2. Place of Disposition /i) 1 Vi.0 lc/ -t - jric 1 ci� t
;; (address)
W
(/)
LX (section) (lot num r) r (grave number)
1/41 Name of Sexton or Person in Charge of Premises a A.R..LA 6 L49-/y
(please print)
W Signature Title G'R 04 1 e l'a.
(over)
DOH-1555 (9/98)