Bolz Jr, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Filist Middle Last Sex
11/'P()t It) , 8doZ 4 r. P1
Date of Death Age If Veteran of U.S. Armed Forces,
0,&" - al/ — aG 0 el War or Dates i(JO
Place of Death / Hospital, Institution or
W City, Town or Village SC 0 O A.) Street Address 6g, niores Rd_.,
0 Manner of Death in.), Cause El Accident ❑Homicide El Suicide ❑Undetermined El❑Pending
U.I Circumstances Investigation
111 Medical Certifier Name Title
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k e d bk rh N6-- N e A l i'7 Oe i\7QY 5cti-thot, kAk 1-/ lal e 7a
Death Certificate Filed / District Number Register Number
City, Town or Village SC-% r- - /6'6-3
❑Burial Date C*eretery or Crematory _
ny['Entombment Address ]
Cremation _>C t ps Aofry °
Date Place Remved
Z❑Removal and/or Held
9 and/or Address
CO Hold
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Mi Permit Issued to / L/ Registration Number
Name of Funeral Home G',i L • Qy---e r()Ner / lime— �6/7
Address �y� /A9(7, I O,
- pchi,__Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CC
Ill
` Permission is hereby granted to dispose of the human r ' s described above as indicated.
Date Issued t �a aC/7 Registrar of Vital Statistics � 7 .( 4:„ c t1/�l.t-P
(signature)
<> District Number /56 3 Place C_ . /-- /t s
I certify that the remains of the decedent identified above were disposed of in accordance with this-permit on:
Z
tit Date of Disposition T I Z31(1 Place of Disposition 'ra,i, €..) -VA"..
y it (address)
111
til
Cr (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises tins , VIA 4
!. /1 (pl ase print
E Signature el Title fR4 etTott-
(over)
DOH-1555 (02/2004)