Lozier, Clarence 1OO )
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
rtii Name First Middle Last Sex
G�I'�n e 2.o zi'e/— /✓la k
Date of Death Age If Veteran of U.S. Armed Forces,
/o1/a 7/a a/ 3 li War or Dates
}• Place of Dea Hospital, Institution or
Z. City,�owior Village M0/'ec� ) Street Address (90 y i..arr1//TA ' ,q cje. 16re46�,1;
141
• Manner of Death Natural Cause El ❑Homicide ❑Suicide ❑tfnde ermined ❑P nding
ua Circumstances Investigation
lit Medical Certifier Name Title
O (Lr. s- 1Otier !l�s�. ri0
Address
i.)-2— PA_t/6 Y.-- 6 i-e-7,-,-E c a I,'-' A i I r
i„,::„:,,, Death ertificate Filed District Number Register Number
City, own .r Village / )Oleeac,c- L/s6,7, Co 7
❑Burial Date Cemetery or Crematory c�
1 a/ ' / -A v7 t'"il /l 2✓;�e 4,J C./'e nwdo 1�/
; ❑Entombment Address
®Cremation O iee,sbi)f--t i 41, I
Date Place Removed
Removal and/or Held
9, ❑ _
and/or Address
t Hold
t)
0 Date - Point of
❑Transportation Shipment
0 by Common Destination
gi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
gi' Permit Issued to Registration Number
Name of Funeral Home ber15,46,r-e. ,c/K/)c-e hiph'le. ,.T'l C 00 iiyg
'' Address
j SAerMa44 4ae, Cori/) , Al, y, /a.8�. .
Name of Funeral Firm Making Disposition or to Whom
E. Remains are Shipped, If Other than Above
Address
IC
tf
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /;-/;2,T'/i? Registrar of Vital Statistics ‘A_-7L o49 e4i_4 c
(signature)
District Number V5t� Place 77)6.Jt a. 410,e_Xect
`1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ttI Date of Disposition/3/2//7 Place of Disposition 2),Lur-e,,,) Cf 24,-/'t
/ (address) /
Ili
U
t" (section) t (lot Timber) (grave number)
6 Name of Sexton or r n in Charge of Premises � i�4,+� G �c.c,�:e.
(please print) ,
Signature Title a ✓'e.. 4-4c.,-----
(over)
DOH-1555 (02/2004)