Wood, Walter NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First ,addle La t Sex/
tAI f�LT 1- rt- l ' no 1,> o o 6 / /0L[9`--
Date of Death / Age Veteran of U.S. Armed Fo ces,
3 // /2 War or Dates ,k)//3-
1 ! Place otDeath Hospital{institutio Ir
City,tfowjbr Village 3v,�wS g uP., Street Address ,th ) f oA)b 6-0.6 7tA - .AJP""
Ct Manner of DeathNatural Cause 0 Accident Homicide ❑Suicide Undetermined Pendi ra
Circumstances Inves tion
W Medical Certifier Name Title
n w^lcT»,,J P M
Address
) I 2_ S.'je , B,,,,,t_ 120 4)6.1,7---P Cpww--)c_
Death -4.ficate Filed , District Number Register Nu ber
City ow •r Village ,,S 0 J LU S Q U 2 C,
Date
J J 17 Cemetery Cremat -'io
❑Burial
n)er 1)i G1-3
`'❑Entombment Address j
remation Q V 1/Lrr� I C.-.3 Q U 4-/v S Q /"
Date Place Removed /
❑Removal and/or Held
and/or Address
F= Hold
in
{ Date Point of
Q''0 Transportation Shipment
Et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home _ maker Punt-GA 01 I 30
Address 11 L a- Q H e S. , Q u,ecn dour y , tie v /i r L 12 si 3(-\
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CC
lit
Permission is hereby granted to dispose of the hum remains descri d a e as i icated.
Date Issued '3)a/ 1 -7 Registrar of Vital Statistics ep
J (signature)
District Number 5(05 Place 1 d n ��a �c�\r1 n th LA. r
I certifythat the remains of the decedent identified above were disposed of in accordancebr)th this permit on:
P
Z
i Date of Disposition .3/47 111 Place of Disposition ed, ( Q ._
', ' (address)
w
to
(section) i (lot number) r (grave number)
Name of Sexton or Person in Charge of remises C 4rotpiW' S ' "i
� ( lease print)
t Signature d( Title e�'Imt��'1c C
(over)
DOH-1555 (02/2004)