Lemery, Francis ti
NEW YORK STATE DEPARTMENT OF HEALTH` ' #IC
Vital Records Section Burial - Transit Permit
.; Name First M.••le Last
fi Sex/7
{ Date of Death (( / Age f�eran of S.Armed For ,
ZIS�I7 8"S-- War orD., . / 93 -I1S 7
01 Place o I.:.th ,H - hstfirtion or
;,z: City, o •r Village 0 U .:,&Q treet Ad d 2 y 0 ,T2lw G ecc C Lit
-1 Manner of Death Natural Cause 0 A t ID Homicide 0 Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title/o 6 /
— 1(g v c ,AL
Address rik
' �R.0n1 C; c CTia . fin)s F t cr A /2 p O/
Dea a 11.1i cate Filed Pict rimer -egist er Number
'' C. To • -, Village Q t0 -..is Q 07 o ` ) l
Date / ( ! Cemetery orrematot
Burial 2 19! 17 ,,J aT f 6,-,'
Address rl
:: :�remation U MC a;,JS-e( 2 27 /(f
Date Place Removed / '
a
❑Removal and/or Held
and/or Address
• Hold
6 Date Point of
N Transportation 1 Shipment
a, by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to '2_ Registration Number
ry1512 Name of Funeral Home nfX rd A, uu ker Fw,er m� O f 130
Addmress
11 Lafa.ci e -. , &Wen%&L , e w thil- 1 a'vy
gil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ri
Permission is hereby granted to dispose of the human rtin3sins described ove as indicated.
Date Issued-I (Q I 1") Registrar of Vital Statistics c-�--2
(sig 'Lure)
District Numberc,') Place o , . -r1 C_ ' I JCL. .
I certify that the remains of the decedent identified above were disposed of in • •- with this\permit on:
Date of Disposition z 11 ((1 Place of Disposition ijit+J (i +4tor ._
(address)
iU
SJ� (section) �lot number) . (grave number)
flName of Sexton or Person in Charge of Premises ihr�tQ r � a lt{
z ,s� (please print) II
' Signature a .. Title eR Ern CaL
(over)
DOH-1555 (9/98)