Houser, Richard NEW YORK STATE DEPARTMENT OF HEALTH
()
Vital Records Section Burial - Transit ermit
Name First A n Middle La?/ Ac�Q Sex
Rkcakcoid -Os IAA
Date of Death Age If Veteran of U.S. Arm d Forces,
6J' / t,�-1 (-7 7p� War or--Dates I451.5--- (O 5-
1- Place of Death Hospital, Institution or-�- "n
W City, Town or illi c G'vtSlika�- Street Address -a\r.: bv..t IZ111AW' (Sch, �-{:P .
a Manner of Dea atural Cause O Accident O Homicide O Suicide O Undetermined ri O Pending
UJ Circumstances Investigation
W Medical Certifier Name Title
o -TG,c wt s I4Ra 1ti1
Address '
ILlatak saf+ 1 G V(LLkV(tf E NI
Death Certificate Filed rDistrict Nuel r Register Number
City, Town or illag vtQ.0 J\[(� 12--
OBurial Date Cemet y or Crematory `
O Entombment Address
reremation
Date Place Removed
z El Removal and/or Held
9—__ and/or Address
Cl) Hold
O Date Point of
05 O Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to � � p[ ` Registration Number
Name of Funeral Home Ro td O A"5 {A -(AA - 1C,t4"Q— 0 ►—
Address 23 Ci01 1 5+ • / Vt MI1 )`
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2 Address
cr
` Permission is hereby granted to dispose of the human remains de.cri• - i i
Date Issued £/ /i7 Registrar of Vital Statistics 4t .
(signature)
District Number 57[5 Place Vt I(ale c 1 rictm '(I-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
UJ Date of Disposition slat in Place of Disposition ,�„��,,,," 1; *"4if c4si
W (address)
VI
l (section) (lot number) ` (grave number)
Q Name of Sexton or Person in Charge f Premises 1,•J
z (ple se print)
tJ Signature Title � M %�'�
(over)
DOH-1555 (02/2004)