Hill III, Charles r - -1 I7�
NEW YORK STATE DEPARTMENT OF HEALTH It
Vital Records Section Burial - Transit Permit
Name First Mid S
(. (Jo i 4-(- en. Or
Date of Death Age If Veteran of U.S.Armed For
' 9 i 7 _ Si-.— or Dates .,Ji'a
P ce Bath � (` Hoe- nstitution
Gi r Village (,Ls� F u,,s Street Address - t,u',J.l Fe-u. S
Mann r o Death Natural Cause 0 Accident Q Homicide 0 Suicide n Undetermined []Pending
Circumstances Investigation
Medical Certifier Name Title
0-66, St f_ARJA,S OA-3)
St Address
12 t(Y) focd Sf . (?i -eIAc -r�.1IS, Aj ' 12gal
th Certificate Filed /� District Nurntr Register Nuj
. .. City, own or Village l-i L er S tf"tl.� .. , 0
Date Cemetery • Crematory /(
D Burial Z l it? Pi (J
Address
:: rematiorr
-•It t-• ri Date Place Removed
Removal and/or Held
and/or Address
a Hold
ill
Point of
Q Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home 'der Ft..We/al ,me.. Of 130
Address
lI Lrzfa.y e fit. , bu.e ernbu.ry,))61,0 LJvrX I a BUY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Wil
a Permission is hereb granted to dispose of the human remaider
sd=_ 'bed = .bye as indi ed.
ra Date Issued O"j i 3 a0('7 Registrar of Vital Statistics A o' '
0/ (s: . . rel.-- - >i,
District Number .� t Place �� �I certify that the remains of the decedent identified above were disposed of in accordance this permit on:
i Date of Disposition 21 mill Place of Disposition 'r4iti ed 6 ^4 tWr -
(address)
W
>LIC (section) Alot numbs (grave number)
Name of Sexton or Person in Charge of Premises /tir,;1 �in r Or
Z 4 (please print)
Signature i Title iR 14X
(over)
DOH-t 555 (9/98)