Britton, Stephen NEW YORK STATE DEPARTMENT F HEALTH
Vital Records Section Burial - Transit Plow
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Name FirstS�.�P ,�/ �4� 8£Last 1
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1
Date of Death Age If-Veteran of,U.S.Armed Forces,
Death,
7 op7- War or Dates
Place of Death /�y Hospital, Institution or
-: : Town or 1 . ( u.& :s 13 Ay Street Address , 7 cr,e2 p�
M of Death Cjl Cause 0 Accident D Homicide ❑suicide' u tJndet nnin ed ri 4-1 Pending
Circumstancesinvestigation
,il
l-r Medical Certifier Name Title
4 • of STot EA/6aPA. /�`/,. 9
ri . Address !b a._ .ems-. S'-7' -of-£.ct5 <, Au ✓oacc -/ •
Register Number
Dg ...,,eedti Tawn Gc�3��� (*mkt Number � _ 1 a,R
CeinAL._ 0'Etti C.,2e1-1A-roi2tafr . '
['Burial,, 74Address 62,72:.,9, E/L Q. £..cN S ism A/,V /`a4 7
Dane Place Removed
F ❑Removal _ and/or Held
i`-,;< and/or Address
Hold
* Date Point of
[i Transportation Shipment
r by Common Destination
•- Cartier
-�A
El Disinterment Date Cemetery Address
• Date Cemetery Address
p Reint anent
} Permit issued to Registration Number
111 Name of Funeral Home <19 D le..- -- �c Gs►L f4 k c, 1 /9i2S"-
Address l
/2 cj,9-.&.r2£ .cl �/_EAFS ,�.4c c_S y /�
Name of Funeral Firm Making Disposition or to Whom
r! Remains are Shipped,If Other than Above
K
• Address
IT
Penniseion is hereby granted to dispose of the human remains described above as indicated.
pi Date issued 10- to- a0!'7 Registrar of Vital Statistics -(Z,o,d i_ K.X. ,.1 Qsal.--,
(signature)
District Number rj(.rS. 1 Place 0 U c.c n$bu r
I I certify that the remains of the decedent identified above ed of in accordance with this permit on:
a• Date of Disposition I o 1 II I n Place of Disposition • Q,n.t V r.w een.4 v r�
- ; (address)
(ssdion) pet number) (grave number)
• Name of Sexton or Person in Charge of emises /''`{ffeime 1 aq».
44
Signature /�{ Title CRC }f'
(ove
.DOH-1555(02/2004)