Howk, Elroy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Li e0% M!ddl \ s03 �� Sex �ai
' I Date of Death �k.,k` t� ®
Age 1 If Veteran of U.S. Armed Forces, q l , \ S
` 6 War or Dates
...„.: Place of Death Qf CI
Hospital, Institution or
City, Town or Village Street Address
WManner of Death gNatural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined El Pending
Circumstances Investigation
• Medical Certifier Name Title p
III . race.
Address trod a Ce3kAlr 6 lens L1\r k 1. �o l
gi Death Certificate Filed i` District Number Register Number
lig City, Town or Village 1�4`d��
Date l Ce wtery or Crematory ,,�
Burial ri \ 2.7 1\2-- vkrk \'tetJv a'�" �'Q
Address rN i /A_) I _ Oc 1 U
iiii ❑Cremation eI�S /" Y �"\
Date Place Removed
fl❑Removal and/or Held
••• and/or Address
MHold
O Date • Point of
aQ Transportation Shipment
a by Common. Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � i') Registration Number
ili Name of Funeral Home 0. rn o A 6S-01 ---;unetaA\ . \ -" o f 3 a
<': Address
t 1 wx_ca,, e�} C? s Que e`er bo - \
g-c�l
in Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
IAddress
A
Permission is ereby granted to dispose of the human rem= desoribed a e indicated. n C to k c
t-� ; i / r v v�
s Date Issued ` )b\yL_ Registrar of Vital Statistics
SQ Place
3 /v � �( `c
::. District Number G�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
5 Date of Disposition 7/27/1 2 Place of Disposition Pine View Cemetery
(address)
LIu Horicon 3A 1
CC (section) (lot number) (grave number)
O Name of Sexton or Person " Charge of Premises Michael Genier
F _ (please print)
LU Signature 1t `- Title Superintendent
(over)
DOH-1555 (9/98)