Daignault, Louis NEW YORK STATE DEPARTMENT OF HEALTH Burial ��"���it Permit
Vital Records Section
Name Firstsu, S Middle LastG '^ Sex
rvi
_> A e . I If Veteran of U.S. ArmedForces,
Date of Deat j ' 9 2 ___— _
`� 23 2 L 1 li 3 ( War or Dates
Hospital, Institution or S u-I k 6j(�k c
Place of Death �j�� /�',0,w / p - C SG �n-C�1 H + -�/ N/
ZCity,Town or Village SO (,('f vl L7 olS71/l S I Street Address ' Ill TD(• :z4'n3
ta Manner of Death IF. Natural Cause Accident n Homicide n Suicide Undetermined n Pending
Circumstances Investigation
u Medical Certifier Name Title
CZ TCt,rG 6'Gli i i £r,Abh1'
Address Q
I 0 Z 1 a'f K S � leM c c/I c1 NRegister m/er
Death Certificate Filed District Number ���
>: City,Town or Village
Burial .Date ` Ce etery or Crematory a�� �y � �o ��- I , v rah LY- A -11 tr
❑Entombment Address ,/ , ( (� Z�
Cremation L��a KC/► �U1 . alh--� Sku./'\1 uy t20
Date Place Removed
Z C Removal ` and/or Held
�, and/or I Address
Hold
CD
0 ' Date Point of
cck 0 Transportation I Shipment
Et by Common I Destination
Carrier
Date Cemetery Address
Q Disinterment
``";:Q Reinterment
Date 1 Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home . T\(t— t-t_:., t—tX\ HO-r'1 - C:;�tl -
Address 1 -c�l e - Lk- v~(_\1` :-, 1 f K Z ;c k
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cc
iu
.: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued .2J3i9/1 7 Registrar of Vital Statistics -t-24 3L '7
(signature) _
<. District Number L-/cZr,)_. Place TCG/.1 C't , 20,c--f et 4--
II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 31 3 i n Place of Disposition 0 j #' Lt .qt°t""N./
(address)
la
CC (section) // (tot number) c.... (grave number)
01
Name of Sexton or Person in Charge Premises ( ( \
ease print)
1 i . 4 / 'lz. Title tRE,a�r�a2
Signature
(over)
DOH-1555 (02/2004)