Morse, Randy NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial c Transit Permit
t Name First Middle Last I Sex
: Date of Death "1 ! Age I If Veteran of U.S. Armed Forces,
k ::: 3 Ii c/1 �' 1 3 co I War or Dates _
1 Place of Death g C kvS S [ Ho � tion -LLfTown or Villa e I [ t( trees Ad 1 �(,k,� ��r
g. ner of Death'��4 Natural Cause D Accident 0 Homicide ❑Suicide Q Un etermined n Pending
Circumstances Investigation
w Medical Certifier Name Title kv1 .-
Address 5 I of v_f it J
. ath Certificate Filed /� 1 Di ict Number . Register mbe
e,Town or Village C J?N S ta, Is 4 �� ILA
Date Ceme or remato
Burial i 3(� g I 1 rY
❑Entombment f�—Q I (�-Q I �� -
Address
RCremation Wkrod r2_,GLI Q,w,e4tshu ry/ ov /2 6 67
( Date ( Place Removed
ZC Removal I and/or Held
2 and/or Address
{re
Date Point of
❑Transportation Shipment
Es by Common Destination
Carrier
<' Disinterment Date Cemetery Address
E Reinterment DateI Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ,\L ZE t^ c- e rx\ hp j1`l C,11 0
Address : �
1 l-c� al c' .- __r- C4'v ,--,--2V 3 1 ; I\NI 1ZE C 1,
Name of Funeral Firm Making Disposition or to Whom
f Remains are Shipped, If Other than Above
2 Address
l=
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3)2$f 20 i 7 Registrar of Vital Statistics c v. \.�-1`^ —
(signaturey
District Number 5b0/ Place 6 ( SFcAt i S,N`j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ll Date of Disposition .3/200 Place of Disposition -'N` t ' t `few
(address)
ill
l (section) kat number) [� (grave number)
ij
Name of Sexton or Person in Charge of Pre PI^' J "^��
(pleaprrinQ
t Signature Title a/0
(over)
DOH-f 555 (02/2004)