Dodge, Susan NEW YORK STATE DEPARTMENT OF HEALTH i `t1, L
Vital Records Section Burial Transit Permit
3< Name First C\ Middle DLoal,c Sgx-
: Date of Death Age If Veteran of U.S. Arme orces,
'/ i f ?;01 -- I War or Dates
of Death Hospital, Institution or
own or Village �ccr-t, (*;A Street Address �pa,,-4. }fir
CManner of Death e Natural Ca Acc ent Homicide 0 Suicide �Undermined Pending
LU Circumstance Investigation
at Medical Certifier Name Title
�c L s s., J C'Q. AZ•
Address
a)t CA►ed,.V-• fir, Sr. (4,-Y- l a'1� �
Death Certificate Filed 'District Number Register Number
c,City,Town or Village SARATOGA SPRINGS •
❑Burial Date / Cemetery or Crematory
❑c;atom •br ent `�l a D�t v r �,, c•.,q-}n f y—
Address c,� O
['Cremation .-tee-t S Kri �e'— 1 c,(�
Date ) Place Removed
0❑Removal and/or Held
trz and/or Address
Hold
La
Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Miiii❑Reinterment Date Cemetery Address
im, Permit Issued to Registration Number
Name of Funeral Home ''vc a(-'c Ae r t, HI.-"/ pc, 'it-,
Address c,
7 .9 P�t,1erA..p,, Ale-� �,4., Al /as�Z
Name of Funeral Firm Makin Disposition or to Whom
fOi Remains are Shipped, If Other than Above
Address
W —
Permission is hereby granted to dispose of the human remains ibed above as indicated.
>s Date Issued 61/ / /A'I 2---Registrar of Vital Statistics T. -4-cit.,,A,
(signature)
gii District Number z j 1 Place SARATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition 1-`4-t1- Place of Disposition H,Uti.J Cn�r-4rid+.
2 (address)
L
CO
CC (section) A _ (lot number (grave number)
e
ifl Name of Sexton or Person in Charge of Premises Lhtpst4pGr 'roe
2 I (please print)
SignatureL l,Title G �n 'u�
' (over)
DOH-1555 (02/2004)