Loading...
Locke, George NEW YORK STATE DEPARTMEN '"'F HEALTH . `.. 1 Vital Records Section Burial - Transit Permit iiiig N9me First ` Middle Last Se -e..©rct G � �GK e- l /via/-L, Date of Death Age If Veteran of U.S. Armed Forces, eiii. 7 ---i c -eDo I R ( rJ' War or Dates V, #vj . Place of Death Hospital, Institution or City, Town or Village I n a t c r) Lat.-A_ Street Address l 301n 'u5- 1 Manner of Death g Natural Cause Accident El Homicide Suicide ri Undetermined ri Pending - Circumstances Investigation 0. Eli Medical Certifier Name Title Dr oil n LA ka ; c z AA Address ("; leis 1I s iip.ii; Death Certificate Filed Districf Number Re ster Number 9J >': City, Town or Village n��� i!Q� ADS 3 l� Burial Date 1 /� emet or Cref�atory aEntombment 1 t 16 )1 f re to7)e i.A Address . GiL,2_,,,, S hi) rtsj : "1Cremation Date Place Reov d ❑ .Z Removal _ and/or Heldm and/or Address t Hold 0 Date Point of TransportationShipment E by Common Destination Carrier Disinterment Date • Cemetery Address > 'Q.Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M) I I e-r- .3c,v22 I L---o rrt C I l it . 1.1 Address 63 51 S 30 )nd i aJ-vt a_kiz Nly i 2.842, ' ' Name of Funeral Firm Making Dis osition or to Whom is Remains are Shipped, If Other than Above Address f iii CL Permission is h reb granted to dispose of the huma e ins s6.,„,..,„„, described above as indicated. Date Issued 7 it, )g Registrar of Vital Statistics L.t L; a (signature) District Number 0..0 Place Ind i Laki_ `'`.`3 I certify that the remains of the decedent identified above were disposed o in accordance with this permit on: k LU Date of Disposition li)g )tg Place of Disposition ..., 42c'ior• a. (address) iii UX (section) (lo umber) (grave number) 01 Name of Sexton or Person in Charge of Premises ` 4r, t^^ z (please nnt) to 4 Signature LU Title (Iyhrtnl/l. (over) DOH-1555 (02/2004)