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Chabot, Burton
NEW YORK STATE DEPARTMENT OF HEALTH' Vital Records Section Burial - Transit Pe mit Name First j Middle Last Sex (�vrld� eW,c-!d Date of De th Age If Veteran of U.S. Armed Forces, n ©y�' AC/ � 9( War or Dates i r c{.8— / ?Y Place of Death � ��r? Hospital, Institution or 5 City, Town or Village Street Address S'E ----1;10A5'€,-7A. 0 Manner of Death,JNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending fa Circumstances Investigation Lii Medical Certifier Name '' Title 0a. 71 rim o 4 PetQ Address A nkt P� 7 /0—�7 C �f �a;r Fi elf Ave- � c.�t �-- AA I, Certificate Filed District Number Register Number City, Town or Village / &_ ElBurial Date / r " i Cietery or Crematory �/ ['Entombment Ol l 7 — V rip N 8 U i'eu) �ern,7Ui•`/ Address :%Cremation �ue.,ops V vs?. Jv Date Pia Removed Z Removal and/or Held 2❑and/or Address to F Hold C? Date Point of ili El Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to / j / / Registration Number Name of Funeral Home t`d •<=1 ,11,/ riibt r A 1 f`i Gw�__- 0 d -`'`rH 7 Address 1°15 STIR fekg S tiiii249 iAeI_ 0. , lz42b. Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above Address In P" Permission is herebyr granted to dispose of the human r ins described above as indicated. Iiil Date Issued Oill/'I /(r Registrar of Vital Statistics /LGf°t_t? ` Vf jtu (signature) in District Number ) 57 Place rS)C- 7Q0 'A-) 4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition L11n h Place of Disposition gt 11� C --4u 2 (address) Ili l (section) L1 (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises r„ ' 'swit ( lease print) Signature f-"r Title '"Pit-- (over) DOH-1555 (02/2004)