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Floor, William
NEW YORK STATE DEPARTMENT OF HEAL. /: 3/Z Vital Records Section Burial Transit Pe mit Name First Middle Last W'r.// fa./Y) b'owai-c( floor Sex MIe <, Date of Death Age If Veteran of U.S. Armed Forces, '4/- a g- 40 1 7 90 y rs• War or Dates j 9 1f _ I O y 7 Place of Death ✓'e vn 0-le Hospital, Institution or 77 Sal)la.+1-\-jai/ 44.., RA , Ai City, Town or Village Naq Lc,e✓ Street Address S i 1 V e r- o.y Eal Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ❑Pending 141 Circumstances Investigation Medical Certifier Name Title PI ' .0bei-+ ,►, 0 rr ul M., -D. Address 1 O a /lace, Tr-aC 1C k_Oasf 1 1 c©n A e i-oaai ,N? a Rk3 iii Death Certificate Filed 779 co n o-c District Number R gister Number 3 City, Town or Village (i'iQ `� u_e -00 63 Date C etery or Crematory ❑Burial s-o? - is 0 l 7 Pr o E_ W ec.0 Cr e n20,.O Address Cremation �C.LE e s i ut t- - N e Lu f\/ o r K. Date Place Removed Z F-IRemoval and/or Held 2 and/or Address 0 Hold Q Date Point of NQ Transportation Shipment n by Common Destination Carrier Disinterment Date Cemetery Address • Date CemeteryAddress Reinterment '"''l Permit Issued to j I Registration Number < I Name of Funeral Home AN /(►o�)( + keQ a /l -Caner-0 I AcM (.2 ) ga. 1 < : Address J n A1gG{ onkIn St Ti�coc ro�ai .N � 3 y ic '� Name of Funslal Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ff Address f f ''': Permission is hereby granted to dispose of the human re ins described above as indicated. iN Date Issued S I-'ab J 7 Registrar of Vital Statistics (Vitt-Li- • //f -+---' »..>.3 nature) Mii District Numbers ,53 Place / a C U /1 0 -P tH a3 ("LE I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F W Date of Disposition 5 4 In Place of Disposition . UEI) l:- aitOri . Z (address) LU N CC (section) iss/(lot number) (grave number) GName of Sexton or Person in Charge of Premises (/� �+ r t��(If' Z L (please print) Signature 47 Title 1f 0)111 • DOH-1555 (10/89) p. 1 of 2 VS-61