Lavery, Charles NEW YORK STATE DEPARTMENT OF HEALTH __ l{s-c-
Vital Records Section Burial - Transit Permit
Name First /7 Middle st SeA
l -4MA f 3 t 6YvT t �72.r �'L(a
Date of Death J Age If Veteran of U.S. Armed Fo s,
/h Pg-
Jo /r( -i Li( . .r Dates -A)}- P .ce of Death t ( Hospital, stitution o/r�
Z 00 own or Village �,ds,,,S /_�Z-L „S. -- 'ddress t,t L�'NS rar,C.S
p anner of Death LrYt Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W _Medical Certifier Name Title
Address Pewk
— f OJ �7,_ 6Tht ,-)1 Ii c Al .,
D h Certificate Filed /'`\ 11 District Number Register Number
Cit own or Village ( •7 6, -,.,s / 6-1,6$
Burial Date /2///
1 Cemetery or remato-r�y�9 p / I❑Entombment+- �� (AJd-- I t1�--)
Address
'Cremation U .vs'a k
Date 'Place emoved
Z Removal and/ r Held
O and/or Address
Hold
0 Date f Point of
It❑Transportation i I Shipment
a by Common Destination
Carrier
- -
C Disinterment Date I Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home -{0,\/nal ci 'b, 6c.k.ker V.-Lulu- 1 iio r;,c.. 0 f l 3U
Address - __ _ _ �_ .__.___1
11 l a�Cky Q. C. SA . , (x uLCCnYour V , NJ e v-.1 yor L. 12 Co-1
Name of Funeral Firm Making Disposition or to Whom —
I- Remains are Shipped, If Other than Above
Z Address --
IX
W _
C Permission is hereby granted to dispose of the human remains described a ve icated.
Date Issued _ /c ei3/20/( Registrar of Vital Statistics /4, ,
_ (signature)
District Number 'S 0� Place 6jrpy,, hi/k '
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 �,'�
ILI „
Date of Disposition Io-Y- ti Place of Disposition 4imeiiiw �.e r►,,,4QC (J
ill (address)
U)
d (section (lot number) (grave number)
p Name of Sexton or Pe son in Charge�/of Premises t i+,nn`�hMUe _
2 f-i'—" i (please print)
W Signature Iy�Lt cw//ti - -- Title C rem dr, ASS
(over)
DOH-1555 (02/2004)