Wadsworth Sr., William „ NEV'V PORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
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>i Date of Death 1 Age I If V�ran of U.S. Armed Forces.
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a Medical Certifier Name 14 0Title
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Death -•- icate Filed I Distri �bbr - V Reg r Number
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�, ` I Date 7Cemetery Cremat71),I)
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i Date 1 Place Removed
Removal I j and/or Held
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ar i Address
0 Date Point of
N n Transportation .I ; Shipment
fl by Common Destination - -
•
Carrier
E Disinterment Date '_, Cemetery Address
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Reinterment Date j-
Cemetery Address
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Permit Issued to _ / I Registration Number
_7 Name of Funeral Home ” R:?i; : Y f, — 1 01130
iM Address j
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'`ii Name of Funeral Fern Making Disposition or to Whom ' f -
14.iRemains are Shipped. If Other than Above `�
Address -
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i- Permission is hereby granted to dispose of the human remains described ove as indicated.
mii Date Issued 23)(Qp Registrar of Vital Statistics 1C---,._ ..,_
(signature)
District Number' Place I Q L. O� /L�=a
:-:-:
I certify that the remains of the decedent identified above were disposed of in a rdance ith this permit on:
Date of Disposition 5/25/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
Erie - 14A 1
CC (section) (lot number) (grave number)
O Name of S ton or Person-in Charge of Premises Connie L. Goedert
(please print)
4. Signatur at t& i-- Title Cemetery Superintendent
- (over)
DOH-1555 (9/98)