Hollis, Willow NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records section ,-. Burial - Transit Permit
Name First W .,i1oUj Middle -am"
-bate of DemM1 III Ape N veteran Of U.S.Armed Forces,
2Gro GAS-' All or Oates
Place of Death Hasid ImeNAan or
Cry. Town or Village 61es (n115, Ny SvamAaaress C.krr> IallS Ihl
Manner as used lqW handful Causes Q Accident QHomii QSUmade DClrcumatencesUMetermineE �PenEinp
Inves "
Maticm GaNfier Name ` am1e a - _ w This ND
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DeathCity rade or Villages f IS D'Ismm Numcar GI RapMar Numear 3
oeurial pmp �IlzlzoZO ale
r eM"to Crema
OEnmmdment. Adams
aemafion a, t ,(i Z
Oate Phase Persuaded Removalunder Held
O anaor Andras
vi N Hold
O Dade pond W
QTransporbibn Shipmem
by Common DapneYm
Canner
DDisintemed One Demmery Andrew
QReime,mem Dme Cemetery Address
Permit Issued W gepietreEm NumEer
Name of Funeral Home W8 K,)mNsr- runeral 00/YlE- [77
Address � ? &Oad �oT� fruvoc), /V IzBz$
Name o1 Funera Finn mining DisWmtl n arro WMm
f Remains are Shipped, it Other tlwn Apove
s Address
d Permission is naney granted W dgfess W Me human nmame described above as indicated.
Ode Issued 11 zo Registrarm Vital Stabancis C
District Heather I Place 66 S AIV
I codify that the remain of the command idemifietl seem wen disposed! W in asndds Hence wad this pmmn on:
Date of Disposition 4JiYJWPlecem Dispmibvn Y� [�
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Name a Sedan or Person inC 9ad Pr ,A
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Slgnatun Title �LTiA{gQ
(over)
DOH-1555 (OV20OR
wwie ReMM Lew sec. maslzn> - 313991
Receipt
Homan remains of delivered on
. 20 r
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wend Cemetery — RepmemOog me fineel home named on bMtl pmmit
Fmeml Uvecmrs Re g. ar LittnaeN