Wemette, Eric NEW YORK STATE DEPARTMENT OF HEALTH ` r3
Vital Records Section Burial - Transit Permit
Name Fi t ddle L tt. t S
Date of Death Age i If Veteran of U.S. Armed Forces,
j/ - 03 - �/ r 7S War or Dates /"d
Place of Death /' Hospital, Institution or �a
Z City, Town or Village c h��D Street Address / '7 Co/e.vs c��
a Manner of Death NrNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name 1 Title
0.Ae- try h,m' .Saaid a, �� 1,9
Address t /�
J4/' Cai..- ` l�Ue-ems. 6ery 0J)4 , iit -c/
Death Certificate Filed 3-)CA
� _ 1 District Numbe/ a Register ber
City, Town or Village 14.
0 Burial Date Cen-4 tery or Crematory
DEntombment /7- 0 .J_— d/r ' e_ VI� hemn I e r
Address
emationv ee. s ij V ry A) '
Date Place Remove
Z Removal and/or Held
2 ❑and/or Address
H Hold
(3 Date Point of
e" 0 Transportation Shipment
O by Common Destination
farrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to � r �// 1 ,-/ Registration Number
Name of Funeral Home C�tuaAvz �_ Vat i dl e rto 11`�CHt c Co 6—/
Address 3c,4 ,-6-0,_ h fl CCU N ,x /d. �, ,0
ig Name of Funeral Firm Making Disposition or to Whom
J
14. Remains are Shipped, If Other than Above
;; Address
ILI
Permission is hereby granted to dispose of the human r ins described above as indicated.
iin Date Issued //-Cr4-90/ Registrar of Vital Statistics 44 c_ c,. . Vet..�u.Q
(signature)
District Number 1 5/03 Place ai, jt) ✓ ,
I certify that the remains of the decedent identified above were disposed of inaccordance with this permit on:
14
tLI Date of Disposition ii 16 II 1 Place of Disposition ;',, _,,
! '' &--
(address)
W
U)
CC (section) 4 (lot number (grave number)
• Name of Sexton or Person in Charge of Premises tior,t IA,*
z (p ase print)
• Signature ""' Title (ROW_
(over)
DOH-1555 (02/2004)