Holmquist, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial -Transit Permit
> ' Name First Middle Last S
/c.L>/4,7 C).Z. t 6 ti/S 7- F.,....>> Date of Death 9A6/215# Age If Veteran of U.S. Armed es,
War or Dates
"'. Place of Death Hospital, Institution or
City, Town or Village Oaf- 6' `/ Street Address 72/ S%AAiro 4(
c Manner of Death 1Natural Cause El Q Homicide El Q Undetermined Q Pending
W Circumstances Investigation
CI
isi Medical Certifier Name Title
Address
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Death Certificate Filed District Nuee Register
N tuber
:� City, Town or Village S 6�--y S� 1 0
:: ( Burial Date g ` Cemetery or Crematory
«» ❑Entombment Address. ` a�/��J l 5` -�4L/ bts u s C�-.Ctic TEA-V
` .['Cremation X -€-6.2.c3` k6,¢--D 64.0- ,fy 8 Lad/ All)-
: `' Date Place Removed
Q Removal and/or Held
and/or Address
t= Hold
In
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
iU::>'-Q Reinterment Date Cemetery Address
iiiit Permit Issued to ,/ Registration Number
Name of Funeral Home 4.�ii,b `-H-j!'C. /9 v75—
>« Address' l Z 0 ,z ? '/ .37: 6-!, E-A6 e-.f_.s At / i&d2 2)J
F<> Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
Address
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"` Permission is herebygranted to dispose of the human remains described above as indicated.
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``! Date Issued 9 I22_Ic)Q l/ Registrar of Vital Statistics . , C . z_
(signature)
District Number q c m Place ( 0 �,., Cj-E ( W -
I certify that the remains of the decedent identified above were disposed of in acc•ft ce with this permit on:
Date of Disposition 9j
Z- i l Place of Disposition 5k-.41 L,,,s,,S ,j LssLi2e.r,� Rc)- GLc rats
to
44 S`Lec',C\ C 9 14Ar ��
( On) number)Apjz_ (grave number)
el Name of S on or Person in Charge of mises W��r C_� Pk - `M�-Lc \k
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1\i
(� (please print)
Signature 11 Title a
(over)
DOH-1555 (02/2004)