Moore, Scott NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middles Last Sex
Date ofDeath CO Moo
IfI Veett ran of U.S. Armed Forces, Ma i(
— I O _ 1 -i 5 1 War or Dates jj p
Place of Death Hospital, Institution or
Z City ow or Village L � ryyz._ Street Address 1(s is Ra boi &'1
W Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
a I I I r.t.M 0 r i u IC Al p
Address
Death Certificate Filed _ I District Number Register Number
City, fIowr��,`1Dr Village 'I-ltat,ram
❑Burial Date Cemetery or�Cre/m+°attory
['Entombment
Addr! -Less 3 1 7 11 n e 'I1 eLc li crn t fry
Qu,rusk xA,
Date J �( Place Removed
gRemoval and/or Held
3 and/or Address
I= Hold
t3
0 Date Point of
t3 0 Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date . Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeP)rt ''er� h jtQ.yzt( -1-/pyl) ( l yiC OO 0Address
�4- Ok u.,--e i, S Lrx ) u 7/en . /z 80
Name of Funeral Firm Making Disposition or to Whom
-; Remains are Shipped, If Other than Above
;r* Address
tr
tu p., Permission is hereby granted to dispose of the human r ins des ibed ab ve indicated.
Date Issued !'131 J 7 _ Registrar of Vital Statistics � , �
(signature)
District Number 56S-4, Place I ;12 n of La p Lu2t i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
>U Date of Disposition I/13 in Place of Disposition ' Oe0,4... Cri^n or..,.
'ii (address)
LU
U,
CC (section) /� (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises
G��s,14
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;Z. (please print)
ill Signature LI Title CG fhb
(over)
DOH-1555 (02/2004)