Breault Sr, Charles iG3if
NEW YORK STATE DEPARTMENT OF HEALTH e ®
Vital Records Section Burial - Transit Permit
Name First 0 Mii dle rDLast SexAi
lit Date of Death j if Veteran of U.S.Armed Forces,/
-I / /7 1 Ara
al or Dates Au
114-' ice of Death Hospital nstitution
Ci own or Village - C ) I-�-L{, eet Address LLJ'�.� /0ZLS
l:. Manner of Death NNatural Cause ❑Accident 0 Homicide 0 Suicide �Undetermined Q Pending
g3 Circumstances Investigation
0
jj Medical Certifier Name Title /
Q /U®bZL(� 7—E-.�e-J� _/'C�>
Address (� r
j C)� �J,(�r+-e3,r„ `\ - �a1nli �L.e7,J 1 F,t??L.S Af t
-ath Certificate Filed cm District Num Register
7Isf/
own or Village
>> :■Burial I Date /Z 3 f Cemetery o Crematory - n
p l / �"(ry U r 6N-.�
❑Entombment _Address---
'Cremation UY�?L�� l_ I iJ 2J,•i j (� vYL�/ l v
Date Place Removed /
Removal and/or Held
and/or Address
Hold 1
Date Point of
Transportation Shipment
Es by Common Destination
Carrier
Disinterment I Date Cemetery Address
` _ Q Reinterment Date Cemetery Address
4 Permit Issued to Registration Number
Name of Funeral Home t .\tiC_. - ;'\LcT \ i--NO M k C •i i P Cs
Address
l L_c, al e- S-ac- C�'. C:-,- i.i 1 I \i 1 LE k c
i' Name of Funeral Firm Making Disposition or to Whom 't
14- Remains are Shipped, If Other than Above
2 Address
LEI
t�` Permission is hereby granted to dispose of the humaeremains ascribe Bove as i dice -..
Date Issued aa�.-a-317 Registrar of Vital Statistics 7' p_p 4,- ,2J`-e.,
sronature)
District Number 5- () Place 4 / FtD—c-agS
/
i certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
,,V,�,Place of
III Date of Disposition g1�'{IQDisposition � 6c7'—
(address)
311
EC (section) Atot number) e
Name of Sexton or Person in Charge of Pre ises (4,4 SU"'s (grave number)
it
(please print)
t Si nature /� Title i"i mil
9
(over)
•
DOH-1555 (0212004)