Holmwood, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
N.mY irst Middle Last Sex
• .i / MN)nnd Met le,
Date of Death Age If Veteran of U.S. Armed Forces,
4 l3 -a t /7 (,e 0 War or Dates AJp
Place of Death Hospital, Institution or
City, Town or a --) CA)r-t r) Street Address a,D 4 {d fn r- Are.
Ewa Manner of Death piNatural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
v in cell t Meyer Mb
Address
Death Certificate Filed District Number Register Number
k-. City, Town or Village A r i n41 Ny
x ❑Burial Date Rmetery or Crematory
❑Entombment 1 — / q"01D/ 7 l nc V1 f t.c) Cr ria1vn
Address
'1 Cremation Q tAccAsb u r J
Date Place emoved
❑Removal and/or Held
and/or
--
Hold Address
i-
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
- Name of Funeral Homer euJ — -F ilf_ I )- rr , 1 tO a II
op Address
01 Church s fax Sins L& /\A//2S
Name of Funeral Firm Making Disposition or to W om
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human - descri ab e as indicated.is
4.
Date Issued I13 I 7 Registrar of Vital Statistics Ailt1dig. 0
G ignature)
District Number 3 Place 1�,� /
�S.�eJ I certify that the remains of the decedent identified above were di lised of in accordance with this permit on:
Date of Disposition colyin Place of Disposition 171:11L.,4 ( -(46--
i (address)
(section) r (lot numb r) (grave number)0.
t.-•'
Name of Sexton or Person in Charge of remises 1 A I I ,� r
Vase print)
Kt
Signature 47),
rp Title ` 0111ro11-
(over)
DOH-1555 (02/2004)