Martin, David NEW PORK STATE DEPARTMENT OF HEALlH ' Burial - Transit Permit
Vital Records Section .
Name First', ____JAiddle //nV^, • Last Sew
• Date of Death Age If Veteran Of U,S, Armed Forces, ,
if0/ .4)/a017 S7 War or Dates
Place D th Hos ital, Institution or
City(wn o Village ) o ,,. c streetAddress >1S Al a'^ Sd ,
o Manner of Death Natural Cause 0 Accident D Homicide 0 Suicide FTUndetermined — Pending
Circumstances — lnvestation
Mu. edical Certifier Na Title_
Cl L e-j erA..) V;1 i K-a.e...i,-1-e---
Ad ess- 0(0.D 5,1„. -* ai,,,,e.) co -n 1J y
Death Certificate Filed District Number __ Register Number
City. wn Village C�r, ..._ II5 7 -'
Date r Cemetery or Cremator
/, 18urial l o 00 / a:.)r7 , •,�V-C;,,., ,-
Address
IX Cremation ,,k`t.n`)h-,rr� �e+.., (A....Date Place Removed
Z Removal and/or Held
Oh
— and/or Address
Hold
0
O Date Point of
cv15 ( i Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date • Cemetery Address
Permit Issued to _ Registration Number .
Name of Funeral Home e.....-/,s,,,,j re e r...- /-4,-`___, v 4,`7`7'6-- •
Address 7 y,..--h 4-ye r..k7 ' (t)7 /?K 7)--
Name of Funeral Firm Making Disposition or to Whom
.H Remains are Shipped, If Other than Above
•2 Address
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Permission Is hereby granted to dispose of the human r: • _ •=scribed ov: . •icated.
Date Issued,j3 / 7 Re istrar of Vital Statistics Atop
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District Number Lis S Place /% -h— �cr`' 'r2
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z Dale of Disposition /11z41I1 Place of Disposition -(one .... �.ms ott..—
LIJ
(address)
w
Cr (section) ,j(lot number) . (grave number)
Name of Sexton or Person in Charge of Promises i ht,�i,�ot,,.r ti
Z (please print) f
Title REM (
w Signature • ti �� �1
9
DOrt•t 555 (10/89) p. 1 of 2 VS.6'.