Sheldon, Shannon NEW YORK STATE DEPARTMENT OF HEALTH = 36(
Vital Records Section Burial - Transit Permit
Name First i Middle K � �� Last Sex
hCtvtn o ► l tCw-ctLe
Date of Death Age -) If Veteran of U.S. Armed Forces,
6— 2,0 J : , A, War or Dates Al//O
l- Place of Death //'' rr ` Q `° Hospital, Institution or r '
CityILI , Town or Village 7G h�'v1r�C L�, Street Address 2 3c5 V c,K Vr,4,�/rQ,�„/4i�
W Manner of Death❑Natural Cause Acciden Q Homicide ❑Suicide Undetermined wv4 Pending
Circumstances Investigation
O.
Medical Certifier Name i ,Title
/1° tt11c..e I .�, k lr i cc_ Ill 0
Address SC>
3 roc.-1 S i. bDc, r rt9 , Ny )2 / 'e
Death Certificate Filed % - ' District Num n� ..' Register Number
1. City, Town or Village',--: � E'Vt 7'j
❑Burial Date �Q� r-� Cemetery or Crematory f
❑Entombment "_ 0 P1 A`P V l\( (i Cir u T-ed
Address Z Q t���i' , j� /y �`-/
Cremation i 7�Q�^ -{J , 1. Cj (.l,e£r z S b GU,/� ,v
Date Place Removed
Z Removal and/or Held
2❑and/or Address
t Hold
CA
d Date Point of
tQ Transportation Shipment
Ct by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 0 SS (cn-, /(yNLLG � E'� � ►" fJ CJ 3 6 4/
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
11
to
ix: Permission is hereby granted to dispose of the human rema' d crib ;Ia. •ve as indicated.
Date Issued Registrar of Vital Statistics -/tit
A '` ; " 4 , (signature)
District Number , Place .1 =_� �-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
tU Date of Disposition 5 j ID in Place of Disposition ut U,,,,,, c , f0r;,,`
2
W (address)
Cl)
fr (section) ,, (lot number (grave number)
Name of Sexton or Person in Charge of Premises / r. v,n1h
_z: ( lease print)
tii
Signature Li Title trit rir
(over)
DOH-1555 (02/2004)