Libby, David t N #ifs,'
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First iddle Last Sex
Date of Death Age Veteran of U.S. Arme Forces,
1-,6- / 2 o c 7 co g War or Dates
} Place Death r,� ,` Hospital, Institution or Y 9 c c> >- ,o
W City, pw or Village Street Address 't- -d ��J
C Manner of Death®Natural Cause D Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
i Circumstances Investigation
W Medical Certifier Name Title
AAIC t A “- FtoPtiii til0
Address -
118 US i 10.E ., '1,4 iv i - i?g'7
Death Certificate Filed District Number Register Number
CityClow�r or Village `'' -"-' yS 2i 3 y
❑Burial Date Cemetery or Crematory
❑Entombment Address
(Cremation -2 1 Cs,--- (k-k. - k* -,
Date Place Removed 0
Z El❑Removal and/or Held
2 and/or Address
i= Hold
E/)
O Date Point of
5 E Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration NuTber
Name of Funeral Home ' '- -- '"'{-- 0 1 0 t
Address
(3 r,-- ..dot -\.__ _ .. '< 2-k
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
tr
W.
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued (.,- (2- 13 Registrar of Vitai Statistics _ le-441/L ✓Y N--__-
(signature)
District Number V`7-10 2- Place -7-•-.) `'(7 r„--- �,��,_,
I certify that the remains of the decedent identified above were disposed of in i ,,,..� ^Nn*sgltUrt• .
accordance with this permit on:
iii � IW
Date of Disposition I I n Place of Disposition 4V l�„w
(address)
ti
CA
1C (section) A
(lot number)cu�,�� (grave number)
CI Name of Sexton or Person in Charge of Premises (' n -' - "`�'
(please print)
Ui Signature (J` Title Crag-frirr TX-
. ...
(over)
DOH-1555 (02/2004)