Scudder, Charles „ ti
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Mst;-::* LC iffe-k. 1-3--s Ne,-,d p.._k-/ c\.) ,6 (-syL_ \ S x
C_=' Date of 1
Death) Age r� err If V eran of U.S.Armed Forces,
l I ( 7 1 Dates ) 9 1 / ) 93 la
. e of Death �” Hospita Institution
6 Town or Village Cj t,(i�,�/S ! e L 5 et Address \( 'i.)S Fi9u c
ner of DeathaNatural Cause D Accident n Homicide El Suicide 0 Undetermined 1 1 Pending
Circumstances Investigation
0.
tu Medical Certifier Name �- Title
Address
I CE l C t o
J utarN s g' �i ^ 12-eo
■-ath Certificate Filed , strict Number Reg ter Nu er -
•TownorVnIag
e 6, F .,�.1 m 0 / 1 .8` _
► curial { Date �/ I `Cemetery i rematt Aj ory•J
f El Entombment' Address j 7 i /
❑Cremation t) 7L`- _i) aU =/US", U�/ A
/
Date Place Removed
Removal I and/or Held
and/or Address
Hold
' Date Point of
Q Transportation I Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment I Date 1 Cemetery Address
gi Permit Issued to �} Registration Number
`= Name of Funeral Home t .\tit_ ;-\e_;-t \ t- D“ --- Cm!1 ,C
Address ._,
t+ Lc:.. o C - -- Ct C._`- k_::.- 1 / Ky IZ`c C`I
>1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IZ
lit
tt'- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued �-1 ( � Registrar of Vital Statistics �C� �
(signatur
District Number 5 6 O I Place ,VAS d,t S ;A.t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p DispositionZI oC«� 21dd Eit >s lJ LV /
tit Date of Disposition .�, if Place Place of ��
(address)
til
c (section) (lot number) (grave number)
Name of Sext or Person in Charge of Premises (7(d212(e. - (or� l el
(please print)
Signature "// `/-r' iCthee1_ vr'
Title -.14.421- r�n�.-�t
(over)
DOH-1555 (02/2004)