Blanchard, Timothy NEW YORK STATE DEPARTMENT OF HEALTH ?I
Vital Records Section Burial - Transit Permit
Nape, First Middle Last Sex �r
I 1 Yi ` A QY�r; "�tJ`�,I�a k
:'; Date of Death Age If Veteran of U.S. Armed Forces,
; /
• —/c? S War or Dates 1)0
Place of Death !! '' Hospital, Institution or ,
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City, Town or Village Wi Street Address 5 .a E I i Z bel-t) s
Manner of Death❑Natural Cause NI Accident El Homicide El Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
,A hn r �. M
DD h lAddre�ss I6kc CA( 3y rac 'e N job l
Death Certificate Filed District Nurhber Register Number
City, Town or Village
❑Burial Da$ o ll 3 p-D 13 1mete_ry ocr m9,tor��lny
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❑Entombment dress 1 ��°a
Address
Cremation ( t_t UnSbekri
`j
Date Pla Removed
❑Removal and/or Held
and/or Address
ir Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
ii
Reinterment Date Cemetery Address
gi ElPermit Issued to ._-_. Registration Number
Name of Funeral Home I k ' .- ;__Av. sari/ ' 0 •
Address r
:_ 5-1 R . Ids 6 , i
Name of Funeral Firm Making II isposition or to Whom
1.1 Remains are Shipped, If Other than Above
: Address
!. Permission is hereby granted to dispose of the human rem ins described above as i r 1 icated.
Date Issued (I (/ . fg f Registrar of Vital Statistics Jroutri
igg (s nilre)
WI
District Number 3)01- Place a
c
X'1 I certify that the remains of the decedent identified above were disposed of i accordance with this permit on:
Date of Disposition (01/1(I1 Place of Disposition ,,ts'! {ors,
(address)
(section) di, (lot numbe0. (grave number)
J
Name of Sexton or Person in ChJ
of Premises r+� t. 4
III (please print)
Signature ' Title fPfltlitma —
(over)
DOH-1555 (02/2004)