LaCross, Alvin NEW YORK�S-ATt DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First it Vt ipered it' Last 1 _�t less Sex
1"
Date of Death Age9 If Veteran of U.S. Armed Forces,
4 L2/(-s► I 2- War or Dates IN yJ '
j,)PI ce of Death Hospital, Institution or
Town or Village G 1,(n,S FW t$ Street Address (( ItteiSon 41/e.
real Manner of Death L=1 Natural Cause 0 Accident 0 Homicide El Suicide a Undetermined Pending
Circumstances Investigation
Medical Certifier Name Al JC e )h 6 Kt``_ , rkok 0 Title M
Address 20 turral S•i-
D�th Certificate Filed � �� �� District Numbe�u r`� \ Regis,um�
City,Town or Vilia9e -i v
Date ii G Cemetery or Crematory
[Burial 4 7.��- 51
- -� J�- k -Sub — - -
❑Entombment Address
OCremation O'Qe4 75 60r
Date _J Place Removed
F- ❑Removal and/or Held
and/or Address
a Hold 4.
4
• Date - Point of
[]Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home )&1 X Fy Y\M"ZiA.. 0,-.4., 01 1 3o
Address 1 ( Q. 12�/ 12.tr ei y
1 j °��s�{t. S -�' «ut.ean��J�n�
Name of Funeral Firm Making Disposition or to Whom
i" Remains are Shipped, If Other than Above
Address -•
Permission is hereby granted to dispose of the human remains *scribed boys as in cat
Date Issued O -) Registrar of Vital Statistics / '"' /�`-�
signature)
District Number S j Place r/J , J
I certify that the remain oft decedent identified above were disposed of in accor¢�nce ith this permit on:
Date of Disposition 7 q 1 Place of Disposition (.1, lido lora ws 4Jy b7 /
Ul A N
Ai (a rase)
6-5
(section) (lot yimber) (grave number)
Name of Sexton or Pe son in Charge of Premises Al.,/
k ! G'/l-�
z �� (please print)
f Signature Title
(over)
DOH-1555 (02/2004) 1