Philo, Earl NEW YOLK MITE DEPARTMENT OF HEALTH
Vital Records Section • Burial - Transit Permit
>: Name First Middle It Sex
Earl oas l to Male
gii Date of Age -7 If Veteran of U.S.Armed Forces,
►111s�i3 7 ( War or Dates
VvUV1
Place . '-• 1 - ,
own 'r dk o Q ,1 S�u Street Addresss� Li) �� �r
Manner of Natural Cause Accident 0 Homicide ❑Suicide �Undetermined . Pending
la Circumstances Investigation
fa Medical Certifier Name l a. bsep\n 1 h 1 Title
Address aQ ku.r r , , C-( er�S ccd 15 , my 3,30 I
`' e Q UL2en 1. Number
k �R� Number
Burial Date et
�-J24J3 �F i(1e.v i e u....)
iiiiiz Entombment
Address(D l i cu r` d ., a LLW �b � , ti o�SQL
I.!❑Ciiiiiii! remation - ---- �1
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
0 Reintennent Date ' Cemetery Address
= l Permit Issued to Registration Number
", Name of Funeral Home Maynard ,'jo -ker Fw eccc i I-1 orr Q 1 130
Address
lig 11. La-ra. e---fe )kreet Queensbur
y � y a New yor- y, i agoy
-'>< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
timidt� r
Permission is hereby granted to dispose of the human ma-ns described abo as indicated.
111 Date Issued i , � Registrar of Vital Statistics �_,
(signature)
District Number c(,c—1 Place l 0 „.r-, LA oc)4-a-
.. I certify that the remains of the decedent identified above were disposed of in accor this permit on:
d�fice witf
Iii Date of Disposition 7/2 2/1 3 Place of Disposition Pine View Cemetery
i'i' (address)
ICO li Hudson Sec. 3 3 10
te (section) (lot number) (grave number)
aName of nor Person in Charge of Premises Connie L. Goedert
(2 ,�-- (please print)
;_ Signatur (ii: ^-- itle
/�-.� (, I. Superintendent
(over)
DOH-1555 (02/2004)