Imrie, David 4 /YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
<= Name Firs pMiddle Last
giii Date of Death/ / Age If Veteran of U.S.Armed Forcesi
?1 /S-- STe War or Dates fj ,4
' e of Death ��^^ Hose:al, Institution or
..!°_ own or Village (L F
6;JJ M& Street Addr:t. / C►2k9-%/10 1 Z,C. g'7
inner of DeaNatural Cause D Accident D Homicide D Suicide D Undetermined D Pending
Circumstances Investigation
I Medical Certifier Name Title
ND
-:.• Address 10Z Par�3i- Gum s ro, s, AH, 12 S o 1
.f.
pith Cei GGcate Filed District Number - Register umber
: Ci Town or Village Q L t2 Fla2C.S 5
_:� Date � � 9 //� ��� C�matory,
Burial J /.J U/ i✓
Address / i
D Cremation Q U 074.t: 'L. ) Q v .s s a ibity
7
Date Place Removed
fl❑Removal and/or Held
and/or Address
Hold
Date Point of
gur-I Transportation Shipment
a by Common Destination
Carrier
hi
Disinterment Date Cemetery Address: El
..:.D Reinterment Date Cemetery Address
Permit Issued to _ jJ1 Registration Number
Name of Funeral Home� 13Y �vfJt�LH Z / iNt.' G►//Cb
Ie Address
,... // 1-11- .oycrn,-- .-:-. 0 06, --,.a.c.a e ay ry I 2,r1-15 (-/-
Name of Funeral Fri Making Disposition or to Whom ' !�
- Remains are Shipped, If Other than Above
Address
iiii
ED Permission is hereby granted to dispose of the human remains described above as indicated.
iM
EN Date Issued `Z I 2t1)5 Registrar of Vital Statistics w
i (signature)
:<:< 6 Place (n/pc U�\
` : District Numbers(DO i S, AI V
.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
6 Date of Disposition 7/30/1 5 Place of Disposition Pine View Cementery, Queensbury, NV
(address)
cn
6 4 B Mohawk 1
tx (section) (lot number) (grave number)
0 Name of Sext.n or Person in Charge of Premises Connie L. Goedert
t. (please print)
Signatur- 7*k _ 4- / . Title Cemetery Superintendent
(� - (over)
DOH-1555 (9/98)