Maine, Charles NEW YORK STATE DEPARTMENT OF HEALTH 443
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex LA
C he .( 1eS N . Mcw I
E_~~' Date of Death Age If Veteran of U.S.Armed Fore , ai E 1, 1>� 2(�I q0 War Dates q J
Pia e of Death �aspit
cCityy C1 \enQ `1 S cs lC'f)S rC� 1 S } jp iCc
ei Manner of Deathr�j taturai Cause fl Accident fl Homicide D Suicide Undetermined n Pending
�` Circumstances Investigation
Medical Certifier Name Title
0 Kioe l le. Sevens 1\ikc
Address too broad St ,, C 1 en S a_.-Uz, NK.1 12 C)I
D h.CertificateFiled District Number Register Number
City, wrr-a-r-Vill C "S � l-q
`<' i Q Burial I Date Comctcry r Crematory
❑EntombmentI
Address
` remation Q tAC� , , aLi_s_zicu lDut.t Li, ( \2%0L-1
Date Place Removed
L Removal and/or Held
and/or Address
CDHold
' Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
-Ej Renterment 1 Date I Cemetery Address
'-,:,:i'i Permit Issued to Registration Number
Name of Funeral Home &. `fie ;"\e(-0,A %-\cc\ C:i i ?L
Address 1„
<= Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
lLI
Permission is hereby granted to dispose of the human mains described a ove as indicat d.
/,r
Date Issued p i Registrar of Vital Statistics
::: District Number a..r� 1 Place � id
)
_ J
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
Z
ILE Date of Disposition /////7 Place of Disposition Pi)/Q vrat) e- { ey
),
Ul
ra (section) /(lotnumber)) (grave number)
CI Name of Sexton s in Charge of Premises ��1��v?( fir 1'
i` {please print} .
Signature G2 J Title Cfa-/-/r7 %J' ��G
(over)
DOH-1555 (02/2004)