Mosher Sr.Joseph E. NEW YORK STATE DEPARTMENT OF HEALTH
Vaal Records Section . Burial - Transit Permit
Name First, Middle Last Sex
E- Vs er 5
Date of Death Age If Veteran of US. Armed Forces,
War or Dates
Place Hospital, Institution or l
Cit ,Town or illa a CvT: Street AddressLL
Ma o Death Q Natural Cause Accident Homicide 0 Suicide Un46termined Pending
Circumstances Investigation
Medical Certifier Name Title
U.
i
Address
Deat�ate Filed District Number Register Number
j Ci , Town Village
`f-SS
I
Date Cemetery or Cremator
!i Burial I��a����i tea/ C-
.. �<.ta-
I
Address
y Cremation
Date Place Removed
ZO ED Removal and/or Held
�- Hold
and/or Address I
7
O Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment I
Permit Issued to Registration Number
Name of Funeral Home G"5"^'�` ,,,��.9 ��-`
Address
Name of Funeral Firm Making Disposition or to Wh m
Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human �an cribed ah icated.
Date Issued /Z�a� Re�istrar of Vital Statistics
District Numbers S Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 2•7-1Y-i9 Place of Disposition
g (address)
Cr (section) (lo?tn mber) (grave number)
Name of Sexton r rso in Charge of Premises L4 1&kf Pit c'k L
(please print)
LIJI Signature Title
;;Ori 1555 (10/89) p. 1 of 2 VS-6!
Public Health Law Sec. 4145(2b) Q 3 17 8
Receipt
-- ;`
Human remains of -: r - r.. delivered on , 20 !
Pi#View Cemetery Rep renting the funeral home named on burial permit
Official Funeral Directors Reg.or License# '