Bingaman, Amy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burials Transit Permit
Name First Middle l..a t I Sew
`- .� o a 8-7 ni Or. LS A/C rl; AJ I /' � t r1
! > Date of Death / Age 1 If Veteran of U.S.Armed Forc¢s,
2/ 7 // 7 q ea I War or Dates ..- //✓g-
Placeace n�h Q Hospital,_lrl�tion or ^A
Z Ci Tow Village Ug2:,isi treetAddress /ZI 0 - 1 o U,JT; � Q
ei Manner of Death n Natural Cause El A dent D Homicide Suicide ❑Undetermined ('Pending
g Circumstances 14'\investigation
0
fa Medical Certifier Name (� Title
.7r cw sz J ( /Ci rt /cg /l1),
A.
Address A / N
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Death C •• i to Filed Dis ct N r i ✓R is r Number
-< City, own Village ( C.Wr g I � ---_.
❑Burial ` Date f Cemetery o remato
❑Entombment 2-/ /� Pi -.J tii
Address
emation 0 Ue-/C 6:1/ i 6-41 a (Hi.,--its Q 1/In-, 7
Date ; Place Removed
CRemoval and/or Held
and/or ' Address
CDHold
Date Point of
r—
ail Transportation Shipment
by Common Destination
Carrier '
li4El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i Permit Issued to Registration Number
Name of Funeral Home .\1-,L. t-L,1 e.:i \ hi-3 c 'k- C-A l C'
Address
\1 LeSal AV . ,,L.,(_,1�\u:: `( , Ny i i E cat
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
w
Permission is hereb granted to dispose of the human re ains described ab vp as indicated.
Date Issued � � Registrar of Vital Statistics ��_CZ �.„
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accord nce with is permit on:
Z
111 Date of Disposition 7I13117 Place of Disposition VW,Ow er rt tort-
2 (address)
ir (section) 9 (lot number) (grave number)
ta Name of Sexton or Person in Charge of Pre ,'ses [ i,- i,,fir,, 144t i
lZ
(pll se print)
Signature Title (PE li ,i
(over)
DOH-1555 (02/2004)