Charlebois, Dorotha •
NEW YORK Si ATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First U----.Uco 1`^ Middle } , LastC`^ac ,e ,S Sex
Date of Death r Age IfV_eteran of U.S. Armed FoYrces,
I \ 1 Z.\ 'ZO 11 % War or Dates
Place _pe th
City(Town Village treet Addres /09 Man n t S t£d
ut
a Manner of Deat Natural Cause ❑A id t ❑Homicide 0 Suicide ❑Undetermined ❑Pending
tti Circumstances Investigation
W Medical Certifier Name �_ , Title
0 W_Vi d all r) (noho�n') {Mend r n ph y f C (0-4")
Address
Death_ -.ificate Filed � b n Di t t�-e? Register Number
Ci Town fir Village Y JWt x- �,
urial Date \ l 'i\ ".2-01, 1
( emete or Cr oFy
❑Entombment
Address (
❑Cremation a 0,0Ai (�IL Cy . , Cu9u?-fib l k7,.-%O"1
Date Place Removed
Z ❑Removal and/or Held
2 and/or
F Address
Cl)
Hold
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to J { !r Registration Number
Name of Funeral Home /I d.41/21-cJ J), /J� F I f )j j t4cI
Address / ' L40-trat
S..f-. i 0W..2sf Z b Utz// , / )2- 304
Name of Funeral Firm Making Disposition or to Whom
1;- Remains are Shipped, If Other than Above
2 Address
1r
in
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date IssuedL laell Registrar of Vital Statistics .,K
��
(signature)
District Numberc(2S) Place i(:-) 6-c 0.��
I certify that the remains of the decedent identified above were disposed of in accord ce w th this permit on:
1 18 Pine View Cemetery
ILI Date of Disposition �11 Place of Disposition
(address)
III Erie 4D 1
l
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Michael Genier
(please print)
10
Signature) 9151An•A-411-- Title Superintendent
(over)
DOH-1555 (02/2004)