Steady Jr., Raymond NEW YORK STATE DEPARTMENT OF HEALTH 1/ 3 q
Vital Records Section Burial - Transit Permit
Name First �(? �� 1' /0 0 Middle \, Las ' i' - Sex IrDateof A IfVeteranofU.S.ArmedForces, �'
.s 1 2 War or Dates
Place of Death Hospital, Institution ofm
City,Town or VillageC � s� Street Address 2 C but L� �
Manner of Death Natural Cause U Accident Homicide ID Suicide D Und ❑etermined Pending
Circumstances Investigation
Medical Certifier Name Title
'�-cS\ .V . SOC 016-' hn
Address ja 2 ' L �( L culkk. a uLch s b,w IV �/ti � i2-D
Death Certificate Filed �11 ct R mber ister Number i
City,Town or Village W,QlkS b
(__a '") o
:::: El Burial Date ` I � Z 0 1 Cemet --A).‘
�VU1 lr Crematory CX-CAA
`Q
Address , . '�(�(., _
� -:
Cremation ] PX A avLe. c� kiedV\ 0 f i zeoti
Date Place Removed
I Removal and/or Held
and/or Address
ill Hold
Date I Point of
Q Transportation ( Shipment
Z by Common Destination
Carrier
[,Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
'-- Permit Issued to ;� Registration Number
Name of Funeral Home Haym Ftrd �, baker nec� � on 30
': Address
1, tafa-wtte of. , bb e_rnica y,)UeLv 'lurk- is 'o'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ii Permission is hereby granted to dispose of the human remains described �e as indicated.
1
Date Issued 1 I t 1 I�1 R Registrar of Vital Statistics ( a �
.(sig to )re)re
Place l v C)± l 'L.cia.s
District Number ��� `'�'�-
1 certify that the remains of the decedent identified above were disposed of in acco •- -1 this permit on:
E Date of Disposition i jj-/"? Place of Disposition )/e7 e- o i a-,-) 6 nJ, o
iIirl (address)
LI
C / (section) (10 number) (grave number)
Name of Sexton • n in Charge of Premises -J u-1,g.✓t C2c;,me.u�e
g (please print)
. Signature Title C
7 g f e- c- ,
i - (over)
DOH-1555 (9/98)