Mattice, Wayne -NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirsA....2_244.1\rdle
Las Sex
Date of Death 77-L.4„ Age If Veteran of U.S. Armed Forces, /mot
2-//0`7 4'9' War or Dates 77 Q
Place of Death jJ Hospital, Institution or
City, Town or Villages 7/Z Street Address// .0
iti
ti Manner of Death Natural Cause El Accident 0 Homicide X Suicide ❑Undetermined ri❑Pending
I Circumstances Investigation
Medical Certifier Na Title
Ad ss
/.2 ,
Death Certificate Filed District Number Register Number
is City, Town or Village �� LS�a i 8
Date C et ery or Cr e mator
1_ Burial v1-//g'/ 7 p-�r-Cs,�GG�
Address
0 Cremation
Date 4Ze-ee-'"-v9--#64-1-4Z Remove
! .
0❑Removal and/or Held
•- aHolnd/dor Address
�'"
Ch
Q Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiii ,Name of Funeral Home �w --/77,0 O->-, d fe- t. Q/s 77
Address Q., fl al (2
20(/7 'L. �J / - fG
i<:: Name of Funeral Firm Making'Disposition or to Whom //
t' Remains are Shipped, If Other than Above
'a Address
W
4
Permission is hereby granted to dispose of the human remains described bove as i cat.Id:
Date Issued ,27//8/97 Registrar of Vital Statistics 4C-'� " i-*-c
iiN //`` (signature)
District Number,cle Q ( Place T � �j.1 . /L t /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
WDate of Disposition 2 /18 /97 Place of Disposition Pine View Cemeter_y ,Queens bury ,NY
2 (address)
to
N Huron 27-A 1
CC (section) (lot number) (grave number)
0 Name of Sexto or Person in Charge of Premises Rodney G- Mosher
z (please print)
W Signature fr-4244Q,, .4-) � Title Superintendent
DOH-1555 (10/89) p. 1 of 2 VS-61