Smith, Charles 1
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
i r Name First Meddleast., Sg
Date of Death Age •, If Veteran of U.S.Armed Forces,
7—13 )-t;i') War or Dates k t s r ,£
Place of Death A Hospital, Institution or f
b City, Town or Village r i. );, Street Address 1-14- (4C„,cii,, .) --
• Manner of Death I .atural Cain Act. dent Homicide Q Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Uz` >. ..� 104 • 1 . )
Address :- }
,'a .� L 0.-1 't z-'t ' L. l—i d
g iiiq Death Certificate Filed: -� District Number Ttegistpr umber -
City,Town or Village C �. S i j
1-1 r late Cemetery or Crematory
t�:7 Burial 7 I j` ` :v i( It , it) , ,) e 4_, . %' ..4,...,.._ .
Address -
•
Date I Place Removed
0❑Removal • and/or Held
and/or Address
• Hold
• Date Point of
.` Transportation j Shipment
a, by Common Destination
Carrier •
Disinterment Date Cemetery Address
[�Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home I' U 0 i+..,-L! --?Lv LI,•i r_-, cL ,,,_, C'vD 0 .
.. Address C
Name of Funeral Firm Making Dispositio i o to Whom
>: Remains are Shipped, If Other than Above •
Address •
•
tx
i Permission is hereby granted to dispose of the human remains described ab ve as" dicated.
' Date Issued j-I c Jt:, Registrar of Vital Statistics L ,Ct. IX. -,, 4-- ,, ---
(signa Ire)
District Number �' , �._:_ a •
'�G S`� Place (`� �� t . ,s-�e.:� .�
I certify that the remains of the decedent identified al3ove were disposed of in accordance with this permit on:
Date of Disposition 7/18/11 Place of Disposition Pine View Cemetery
(address)
Horicon 3C • 2
-.f (section) (lot number) (grave number)
0 Name of Sexton or Perso i Charge of Premises Michael ;Genie r
(please print)
Signature Title Superintendent
(over)
DOH-1555 (9/98)