Saunders, Herbert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section /Ril
Name First 5112 r-Kr bent Middle Cep- Last 5�,uod odic Se �J
`J1
Date of Death 1 Age I If Veteran of U.S. Armed Forces, I;w '1
y , I� ' Ig 1 q4 War or Dates nI_-�
Place of Death E Hospital, Institution or / Q-o �t ``"� �`apf
zi
City<f' 1w or Village HOrCO-A-- E Street Address to g /LLAS-(br&c `d .
Manner of Death Pa
Natural Cause 0 Accident 0 Homicide ❑Suicide El Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name i Title cz Q ���. 1- ' 1 n►n V P I \
:r Address 161( CCU G ' , v la)N(� / 4 1 2 �l
v Death Certificate Filed sistrict Number /� V 1 Register Number
iii City To , or Village M O r C-Q.c r s ! Z 0
Date ( Cemetery or rematon�
0 Burial l 'Z i 20 18 pine., (,)l
Address �,
Cremation` Qll,9�.��k r / �l C�� rL,f`��'�f,tJ�C4 by 2
`•• Date Place Removed
0 Removal ' and/or Held
and/or Address •
Hold —0 Date Feint oT
Vim?. ❑Transportation i ( Shipment
.. by Common ( Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment ' Date Cemetery Address
`� Registration Number
_ Permit Issued to `
Name of Funeral Home '6C,ker �uS era\ \-NoMt - E� O\ 3p
,
Address `1 1.--C daye}e.- rc e.a- Q v.eeynsb ---1 , N`f. 17 ?04
F< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:k- Address
a Permission is hereby{{ granted to dispose of the human remains described above as indicated.M
Date Issued y/2 $-- Registrar of Vital Statistics - M.4—`---
(signature)
District Number V S(, 2 Place 7Z Q/7 d r ✓9 L Q.�-
ii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
9
eDate of Disposition Val Place of Disposition P`L(1,.., (1.---14---
.2 (address)
al
SA
g. (section) Rot umber) (grave number)
2 Name of Sexton or Person in Charge of Premises .. , �•"
(please print) V
Signature ,, Title *PARA
(over)
DOH-1 555 (9/98)