Fish Sr., David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
79uIi) i .3.--laM6,-3 F cii- SrL S
Date of Death / Age if Veteran of U.S.Armed For ,
/ /zL/ /e S`) War or Dates AY 10-
Place of Death //� Hospital,Institution or .
} f City, Town illag hi J 0,so,.> I$-r c S (S`treet Addr 7 if -P- R -YL L 4 L fl_
P Manner of Death,lNatural Cause El Accident ID Homicide El Suicide u Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
g, Address
/o 2- * jL ; . ('L J ) I, <Led/
Death Certifi • - District Number Register Number
City, Town . Village )u ce,.i F— s 57 (, c l
Date Cemetery o(Cremato'
o Burial / 6/Z�/s- P-hs 0)0,-)
Address
i remation Q U A lv\ /2--Q) Q t) ../s d k.1
Date Place Removed
❑Removal and/or Held
and/or Addre s
ri Hold
d Date Point of
` u Transportation Shipment
,z by Common Destination
Carrier
;' ❑Disinterment Date Cemetery Address
[�Reinterment Date Cemetery Address
Permit Issued to Registration Number
.r Name of Funeral Home H m rd V. esker F�'e'cti homer Of 13O
Address
/J La a.yfi* of. , 0ukensbLL 1JJe24.) t/orl-- J0A
Name of Funeral Firm Making Disposition or to.Whom
Remains are Shipped, If Other than Above
R• Address
i Permission is hereby granted to dispose of the human remains described above as indicated.
LP Date Issued/Gr•6.5`•a°l2 Registrar of Vital Statistics d„D_
(signature)
District Number--5-7( ,6 Place \ ,ai-o-pie-- Tcl-_-0-.0.-,--- -
I certify that the remains of the decedent identified abo e were disposed of in accordance with this permit on:
• Date of Disposition to /Zb(Ik Place of Disposition 'Qv tr"v1 _
(address)
,i 4 (section) (lot nu ber) (grave number)
Name of Sexton or Person in Charge of Premises I t o
I (Please print)
Signature Title (g/ iOL.
(over)
DOH-1555 (9/98)