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Shattuck, John
if 3e7 NEW YORK STATE DEPARTMENT OF HEA Vital Records Section Burial - Transit Permit Name First iddle Last Sex a S s II C '►i / ' Date of Death Age If Veteran U.S. Armed Forces, PZ 5'l0- 1 +640 War • dates , e Place of Death _ Hospital, Institution or Cit Town or Village Gen 5 do_ 1 Street Address B en5-Fa I 1 85.ta/ Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title -Am. 3ehn .. - Address OY t Death Certificate Filed t~ District Number Register Numb er��l1 EV City, Town or Village �k n 5 t • a d% Nrt• ❑Burial Date C- etery or Crema .ry rn• ❑Entombment 5� i`! )� I J il'�' Address i'Cremation 1fi r .I i t, 1 Date Plac- Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address ,NI21 eti Permit Issued to _ Registration Number Name of Funeral Home .ice L. _ .', Al .L •aak , A L ©Loa Address c `l- Cku,r-c, 5 - ! La. / I, ki 2 L, to Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 51 i`i,/20 Registrar of Vital Statistics W - . Pr- (signat e) mr- vi District Number �60i Place iJ C \S \\S 0 r i p I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 5/jig' Place of Disposition K,Y., 411.0 low./ (address) (section) (lot numbers (grave number) - Name of Sexton or Person in Charge of Premises "+ .+tf /7� (please print) 04-4 Signature /.. lik-- Title f vrovoi'iYL .04 (over) DOH-1555 (02/2004)