Watson, Walter NEW YORK STATE DEPARTMENT OF.,HEALTH
Vital Records Section Burial - Transit Permit
Name First Wal-i-e� Middle Last �vGt � Sex
Date of Death 5 Z 1 i ' , Age q L1 If Veteran of U.S. Armed Forces,
1 War or Dates
)- Place of Death Hospitanstitutior or
Z City(Tow�r Village Pi ' Qv `c�. Street Address I— 1-1UUl
ci Manner of Death Natural Cause D Accident 0Homicide Suicide Undetermined 0 Pending
I1 Circumstances Investigation
Medical Certifier Name Title
o I IN rill--i I6) AI i &,� it di
Address
Death ificate Filed District Register Number
Cit Town r Village I1-- �0 fro 01-5
Burial Date 911511� Cemetery o Cremato 3 ?i( e. Q J
0 Entombment Address
{Cremation Q ,) Q,134_ , 1��- a i.04
�: Date Place Removed
Removal and/or Held
C2 and/or
Address
t: Hold
to
O Date Point of
thElTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
iiig
El Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home Al-ve r ��. e.2A\ HO is t. l 1 L
ti Address
II Lc\. l C -- Si...:* - C.a\k:._��� v r 1 1 K1 rZ C y .
iiig Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
LGt
n" Permission is hereby granted to dispose of the human r ains describ d
as ove a indicated.
Date Issued 15- 11 Registrar of Vital Statistics i: (.L' V
(signature)
District Number 5 Place (l
ig, i
"'• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 5/4/0 Place of Disposition -gicil.w ( c',,..,
2 (address)
ill
fil
EC (section) ,, (lot number) r (grave number)
/Ii• Name of Sexton or Person in Charge of Premises L lrL itv'il l
Z ( lease print)
lilt Signature i.9 Title (kW 2
(over)
DOH-1555 (02/2004)