Long, Dale NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First I Middle Last Sex
AA
di Lc Z � 1-
Date of Death Age If Veteran of U.S. Armed Forc ,
it 1i / )e i 5— War or Dates _
-4 Place of Death Hospital, Institution or --T.
y ,
6 City,( ow)r Village W h A�_ Street Address ((77 c l. CT c.e J�
Manner of Death Natural Cause Accident El Homicide 0 Suicide ❑Undeterred ❑Pending
It Circumstances Investigation
tu Medical Certifier Name Y Title
Q t.'\r s'. —A- ✓ill--�
Address
Death Certificate Filed + t District Number Register Number
City,��,eiwn o Village t't L e
S�% 3
❑Burka Date Cemetery or Crematory
['Entombment Address
;
JO 4_0( I nevi�w C2��-- /"
Address,^..t
>>;: ®Cremation Clean- -c,yb,Az
Date / Place Removed
Removal and/or Held
2❑and/or
� Address
t
Hold
0 Date Point of
E .0 Transportation Shipment
3
5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ��1 s44,�tc f:mot,.,.(, 1-4 ' , D c `I`1
<:+ Address 7
f 5'briny` Ai/C GoP Jl) /a ba _.
< Name of Funeral Firm Making Disposition or to Whom '
Remains are Shipped, If Other than Above
Address
i
LEI
P' Permission is hereby granted to dispose of the human re ins described above as indicate
<+. Date Issued / j Registrar of Vital Statistics 6 -r-,e,
(signature)
NI District Number I/s Place � d`X
I certify that the remains of the decedent identified abo a were disposed of in accordance with this permit on:
14
Date of Disposition I I I I lit Place of Disposition fitii.j 4+,
2 (address)
W
CA
l (section) (1 umber) (• (grave number)
0
ci Name of Sexton or P rson in Charge f Premises (^"' ��-r' i s-Al-
(please hint
E! Signature Title X,• 1jemfl��
9
(over)
DOH-1555 (02/2004)