Hoague, Florence %, NEIWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name cEirV Middle ast S
a�-e�.c� L..; l I I c��-� _ (' u-Ze(l
Date of Dgath A e If Veteran of U.S. Armed'drees,
0I a.g I a:O)a ' cg War or Dates
too Plac- : e-.th � Hospital,Cutiostit or r _ S l m(�,t��
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6 Ci , Town o'Villa Lt.. r�� Street Address 1�v
O Ma - • Death I Natural Cause Ac ident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
tu Medical Certifier Name Title
CI
�osl Un Socc�lof.
Mi.
Address
JS+e m(Lt( t - Curne Lri DuLe_s/n S 6Lt
Death -rtifcate Filed District Number RMteSlumber
City, own or illage 0 ► .+ •"
Burial Datec) i or Crematory
❑Entombment 1 '_I s ao 1 Me i (NIL \h e !J Olin .
Address pp
OCremation t�.Gl K� t d •, 0 L-..o_o_n-101.,t.rl..
Date Place Removed Q
Z Removal and/or Held
❑and/or
Address
I Hold
C0. Date Point of
r_iTransportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Maynard D.der Funeral Home
Registration Number
Name of Funeral Home 0117 .)
Address 11 Lafayette Street
QLeensbur
Name of Funeral Firm Making Dispo n �
o • ,e om
liS Remains are Shipped, If Other than Above
Address
g' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) , �Y' �'{ /�,Registrar of Vital Statistics , C�0).>'1,..:_
(signature)
District Number Place o
I certify that the remains of the decedent identified above were disposed of in ccord ce with this permit on:
E
tad Date of Disposition 1 1 /1 /1 2 Place of Disposition Pine View Cemetery
r (address)
LU i' Mohawk 25 2
(section) (lot number) (grave number)
iS
Name of Sexton or Person in Charge of Premises Michael Genies
Z (please print)
LU
Signature ''L Title Superintendent
(over)
DOH-1555 (02/2004)