Fosbrook, William NEW YORK STATE DEPARTMENT OF HEALTH 4 Z cIC
Vital Records Section Burial - Transit Permit
in Name First fiddle W ` Sex ,,t n
Date of Dea , Age if Veteran of U.S. Armed Forces
f / 71 War or Dates V A
Place of Death ' Hospita, nstitution or j
Cit , "own or Village ��Le',�S Fel L.J reet Address C i LLJ`�S l f�Z�s ___�___�
—
nner of Deaths natural Cause Accident Homicide Suicide Undetermined n Pending
Ill �"'� Circumstances investigation I
0---Medical Certifier Name i I Title
w /7e16� V el& UC 34c
Address
Death Certificate Filed ' District Number y Register Number
City, Town or Village _ 5 Q 1 2 )
Date , Cemetery o Cremator)
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El ` . 4\ � � P-'1- t.
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Cremation�; Addr 4.140(14" 12.41 � g �,j
Date Place Removed
Removal 1 i and/or Held
. __- 4__ _. w ______. _;
Address
Hold
to __-_______._- _ ______ __._._.____________-_-----_______
.�
n i Date , . -lint cif
Transportation Shipment ___�__-_ _ .
E by Common Destination
Carrier
Disinterment ' Date Cemetery Address
Date Cemetery Address
QReinterment
Permit Issued to ; Registration Number
Name of Funeral Home"/C if i I d 0- t..�JC'Lkr .` f-4-alC al Horne_
Address /I LarC ...i C fC' . , a'(,k..CL r/SiOLL C_j , "{Jew i Y4jr/L t c'c1 ----------1�t J
AName-of Funeral Firm Making Disposition or to Whom _�---�"
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above,as indicated.
Date Issuea 4 i
1 (0 1 1 Registrar of Vital Statistics LAD s
(signatur )
District Number 5 to I Place 6 (cd,A_.5--7i :� , ► .) y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZDate of Disposition 1)111 n Place of Disposition R.til( , ( m4trt)(1�, _ __.___ __
2 (address)
W
fJ,1
'ir (section) /) (lot number) (' (grave number)
Name of Sexton or Person in Charge of remises CI t 4nsj 11 , J1�ni�}_
�I� (please print; ! C�'
(-( Title tikmA ivr�, I
ii Signature -i
t
over
DOH 1555 (91981