Moses, Virginia la,
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name Yirst Miciv:111 e Last Sex
!:w i r a 0 ,,..,
to Date p,Deatti Agp), If Veteran of U.S.Armed Forces,
04: t I -2-7-016/3 1 7 :War or Dates
i!'',,, -4 k*-11`.
Place of Death Hospitai, Institution or
:•.• City(f-v Street Address 1,c-4:;)ir Village Co r. ^--&•(----
:. • Mann Death
ii
El Natural Cause 0 Accident El Homicide 0 Suicide
, I 5---- R 0 n
El Undetermined Pending
'Circumstances 'Investigation
Medical Certifier Nam Title
S-7.A.••At K-•./\ /fr\D--•
Address
ptt.,,, 4ve -.. /s. i_.L. . Ni /.)_ (, -)---_
WA:
Death Certificate Filed ..,.. Distriot Number Register Number
1,1 City&9-1 r Village .._ 0 f,. ..t. . --- 11-5-5-3
Date Cemetery or Cr atory
El Burial 0*it a , :),___
Address
LJ Cremation CAD-&G e A
Date I , i Place Removed ni Removal and/or Held
0 1---I
= and/or Address
221— Hold
fn
9 Date Point of
is 0 Transportation Shipment
25 by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
.....: rn Reinterment Date Cemetery Address
Li
Sil Permit Issued to .-- - Registration Number
ill Name of Funeral Ho ....--".s,..a ,-C. —la ri e 1'.., I. k"/ - ,--- l)a 474'I'Y'
t:4 Address
M7 r, 4: -- -:-.....4 - 1J Y /" ..
ill Name of Funeral Firm Making Disposition or to Whom '
E2140 Remains are Shipped, If Other than Above
siNg Address
a Permission is hereby granted to dispose of the human re ins escrib, I boy indicated.
im
Ati Date Issued I I -2.8'-II Registrar of Vital Statistics
signature)
a
District Number Place Olyzio-W17_2,-7
V--%-3
I certify that the remains of the decedent identified above we disposed of in accordance with this permit on:
Date of Disposition /1-- 7-•I Place of Disposition p;A e, V cfr)
2 (address)
ILI
CA
• Name of Sexton or Person in Charge of Premises
(sector?), (lot number)
Jczr-1"e,Y S V-A;r.,5 (grave number)
§
Z (please print)
Signaturera.-- Title C rtd"Ci ital.
(over)
DOH-1555 (9/98)