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Sumner, Charles
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit t. < Name First a—" Middle Last SeA 6 S )S &J �'J 17 Ai 'c_ / 7 elti- m Date of Death Age_ - If Veteran of U.S.Armed For ,t, �;` : / /3 // War or Dates � } 14 Ciac ath ,�a tion or 2 ( hi-City, Town r Village � ub�;n.i�r3 eet Addresses ,93 Co 10 Manner of DeathNatural Cause 0 Acci ent El Homicide Suicide El Undetermined Pending t Circumstances Investigation Ai Medical Certifier Name © Title AA K 6Bl ! L T ./13) Address /Clb ao R -C CDte,./s /I-,e s, / 1 Led/ Death icate Filed District Nu ] tier Number Ci Tow Village 0 ..t►3 6, n �� n (t (NO Burial Date / / Cemetery piremato9ryy j ❑Entombment // /,J tr 1J/61.3 -ii Address � OCremation J�'ILis�. i2,^ (,G Q U .r-S a 4 / z Date - Place Removed '❑Removal and/or Held bt and/or Address Hold 14 Date Point of Transportation Shipment f by Common Destination Carrier 4 ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address tig Permit Issued to Registration Number Name of Funeral Home G/flat d ,_.(''_ Fist"0_1 iAc,( 0 i i 30 _ Address 1‘ L O y Q.Tl e- SA. , Q peen sbi,f y , NJ e v� Vc,r 1i; 12 O iiiir Name of Funeral Firm Making Disposition or to Whom 14 Remains are Shipped, If Other than Above • Address It tit Permission is hereby granted to dispose of the human J remains described above as indicated. Date Issued .l [ 1 a( �-U Registrar of Vital Statistics 'KG.,-,____ . _ _G _ ---- f�''gnature) District Number ��' Place i U ` I certify that the remains of the decedent identified above were disposed of in acco ante - this permit on: la Date of Disposition 1 1 /7/1 1 Place of Disposition Pine View Cemetery 2 (address) ua to Huron 9 C 1 tr (section) (lot number) (grave number) Zt Name of Sexton or Perso in Charge of Premises Michael Genies. a . (please print) sW Signature _ `. Title Superintendent (over) DOH-1555 (02/2004)