Sprague, Baby NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name irst Middle Last Sex
in, Date of e 1 Age If Veteran of U.S. Ar med Forces,
1i3/i 1 0 divv War or Dates —
14 Place of Death S (3 I Hospital, Institution,pc
City, Town or Village aG✓k$ Eq Street Address 6109, TwO IibsP'c 1
0 Manner of Deathatural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
ii Circumstances Investigation
iii Medical Certifier Nam Title
Ekr Pail/ 3 ,0y4J hID
Addre s
(( iS '21(.s l\(-y
Death Certificate Filed //' District Number Register Number
City, Town or Village bl trd c(( 5 0 ( 3
❑Burial Date C etery or Crematory
❑Entombment Address
���"/�� 1hL or 1,1 c/r/Y)Ctoiy
'' � //
iiiiM ►ir remation Z( Q�JC�I��-/ ! 'I, QJ'f�S6 jj& /Zi-V,
Date Place Remove
Z ❑Removal and/or Held
and/or Address
F=` Hold
5. Date Point of
ti0 Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 4-f tic � i:- ('.f . 0(36 37
Address , cc
-3&A < ,,, S f' - W"nn.),t i / Aq f ems'
iN Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Ir
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
KB Date Issued 5 (( 5 / 7 Registrar of Vital Statistics V`'Q)._)'•./y-v-,S2., .�/ M
(signature)
District Number S l� Of Place G (VJs % 1\s 10 o
<a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI Date of Disposition S I Il I fl Place of Disposition end iv, at.,,_
a (address)
Lu
CC (section) /' (lot number)< (grave number)
Name of Sexton or Person in Charge of Premises at b•- 31mA 111
2 ( ease print)
Iti is Signature e� Title `1I,IlD L
(over)
DOH-1555 (02/2004)