Chapman, Webster NEW YORK STATE DEPARTMENT OF HEALTH 4 3L
Vital Records Section ,,_, Burial - Transit Permit
Name First ast i Sec LtviiliroA, m r ►-lam
Date of Death ` „ Ag c eteran of U.S. rmed c ��++
_ + ` � �5 War or Dates �� �(Q�
Place of Death Hospital, Institution or ^�e `4"e
City, Town or Village Street Address , yo
Manner of Deat Natural Cause Accident Homicide Suicide u ��'ndetermined Pending
Circumstances Investigation
-- O I
Medical Certifier N T
2 dilless 10
411.C
Death Certificate Filed vuti_ District Number�..75 Registeeumber
City, Town or Village OLVA)
+ , �
❑Burial Date 1 I ie� Cemrijem ter '7/�(^'ElEntombment Address
V-6remation 4 ,
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
111 Reinterment Date Cemetery Address
Permit Issued to 1ie (c Re t/ .ymber
Name of Funeral Home �//
Address j leName of Funeral irm Making Disposition or to h
q
Remains are Shipped, If Other than Above
Address
Permission is h reby ranted to dispose of the human remains a cribid abo i dicated. /l rA `„�
Date Issued I ct 1 7 Registrar of Vital Statistics r�"
S-7 S ( ,A (`} {4 , (signature)
District Number Place �r C`J�(-4`-�I1'w I �� n
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition t///7l/7 Place of Disposition r�1�►et�i �' L�Cem4
/J (address)
(section) 1 (lot number) (grave number)
Name of Sexton or P s • harge of Premises i�/i cat 6'4414c-.L.-1-1
(please print)
Signature Title -r.a d
(over)
DOH-1555 (02/2004)