Stapley, David 36-7
NEW YORK STATE DEPAR�AEN 1OF HEALTH p - sit Permit
Vital Records Section Burial - Transit
Name First Middle Last Sex ti
D a v� a --Gt �el�c-e, S+&p I-cv
Date of Death Age I If Veteran of U.S.Arm Forces,
LI RQ I i� 70 War or Dates j 9( q - I c D
Place of Death Hospital,Institution or •
, City,Town or Village C ufens� kv Street Address 1 lrerl Ce t,
ier-
-' Manner of Death Q Natural Cause u Accident n Homicide ID Suicide 11•` Undetermined n Pending
Tr rcumstances Investigation
`:%, Medical Certifier Name v_.., St, Title In n
...f; Ukil CO 1(Yr
Address -}-
=� WOL- f-C CuS biti( ) e� yo r
Death cafe Filed �t Number RegistLi er Number
F. City own`.r Village U& -Q't 10 L A (.9-C� -�
Dateetery or emato
0,Burial 1(9 I i v
Cremation Address ,t „ ' a• ,,,, , r XL1\(, mt Vi \loyt,
Date 1 Place Removed
0El Removal and/or Held
E and/or Address
a Hold
2 Date Point of
w['Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home HCt ynard b. sec F Nrhome_ 01130
Address /, Lafc.ye#e of. / br cQanS ny►_J_ec� +-lock- 1agOy
-1 Name of Funeral Firm Making Disposition or to Whom
I.y Remains are Shipped, tf Other than Above
' Address
T
Permission is herebygranted to dispose of the human r -ns descri a �e as indicated.
t f
Date Issued`I.1 1 1c.U? Registrar of Vital Statistics
3 ggnature)
'•' G.
' District Numbe(�c� Place L L.--N CC L,
I certify that the remains of the decedent identified above were disposed of i .accor ante with this permit on:
W Date of Disposition hJ igj f i 7 Place of Disposition 2 i�1 J� C ;eWt A�u f,//
JJ (a ress)
W.
EX (section) t ) _ (lot n mber) (grave number)
0 Name of Sexton Per o in Charge of Premises ! Q Cr..vn G.v1'L
(please print)
W. Signature TitleC. v zC f
(over)
DOH-1555 (9/98)