Hayward Sr, Glen NEW YORK STATE DEPARTMENT OF HEALTH t ,,� BUrIaI _ Transit Permit
Vital Records Section
Name it Mlle ast Sex
Date of D t Age If Veteran of U.S. Armed Forces,
pp�, i6 War or Dates /,�
#-- Place of eath Hospital, Institutio r /�
City, Town or Village// _r/'i/43� Street Address jx f� S`/ 6/ -fi ,/l c
W Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑ Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name , Title
gi /a-//9i/1 ,! /67X(iE- P?-..&,
Address e o? Pgie _J% L/C/ /�/4 /!/7
Death Certificate File District Number�-� Register u b r
City, Town or Villag C6,'5 �/}/.S H , ,,,/
1:,,„„ ❑Burial Date Cemet or Cremate A7/0200 6 ,N/e V o cie -_ n_,e7/ i❑Entombment
Address / Y
;:icremation SO6 4 // ,(_'�/%�
Date Placiemoved
Z ri❑Removal and/or Held
and/or Address
F= Hold
0 Date Point of
i Transportation Shipment
tl
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 0V---7" Al 1Zt / 7C 6- e- 0/57/3
Address ,›23
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
4Li
'` Permission is h reb granted to dispose of the human remains des ib d a ov s in "c to ..
! Date Issued / do Registrar of Vital Statistics /`�"V 1,/
(signature)
District Number56^(�7 Place !V!CC f/QI/S /v;.
..:>;. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t11 Date of Disposition ' I? 1, Place of Disposition ri wW�r r en 16,:^ i ,- -,
(address)
ili
to
CC (section) / (lot number) (grave number)
gt Name of Sexton or Person in Charge of Premises L S (please rint)
zr
tiiSignature ?� �` Title ( ►a r k
(over)
DOH-1555 (02/2004)