Olmstead, Wesley NEW YORK STATE DEPARTMENT OF HEALTH r6C4.`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
VJ eS1cA\ i!• 0\cr . t \L
.� «.ii Date of Death Age I If Veteran of U.S. Armed Forces,
9 -22- ACo War or Dates
'' Place of Death , Hospital,Institution or na
City, Town or Village N\�",.,JCpct\� r
Street Address \`0 `" \. . CIA-. �c-0�
Manner of Death Natural Cause E Accident ❑Homicide El Suicide 0 Undetermined 0 Pending
Circumstances Investigation
t)
iti Medical Certifier Name ( Title 4V�
Address CO '� w C\ /o \G\��C-L-v& \ZC\��O
Death rtificate Filed `` ir X.� District Number Register Number
idil City, own or Village I exi..)Lo 1559_ 5-ZU121
'`i 0Burial Date I _Z.k_t46 Cemetery or Crematory
>`❑Entombnientl p\�" \Y�e"v�
Address \\ �` •
:i 'CCremation Qucr,C-2r � a �eC.�� %. ,Q\
Date Place Removed J
in Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
E by Common Destination
tiiii Carrier
0 Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
<> Name of Funeral Home MSS \‘'- \ -t\c c o \O 11
i]iiiii Address
iiii
iiiil
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 ascribed abov= _ - ind - i=d.
Date Issued 7-01 r j g Registrar of Vital Statistics Q,(,(J .
c (signature)
District Number /55-9 Place NQ,(l
imes:::::.> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition P ?��S-tY P Q►nt_d_lf,c,V cdfvrqiory
(address)
(section) (lot number) (grave number)
I Name of Sexton or Person in Charge of Premises Jtrrelc'Y 2S'ir-<-S
(please print)
Signatures Title Grt.mc,ior
(over)
DOH-1555 (02/2004)