Williams Sr, Scott .,, ._ _ , „ ,t- Els-7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last
S� 4?)i it Ct/Y1S Se . 11' �1e
Date of Death A e If Veteran of U.S. Armed Flu) c s,
�j (y— /�p e,5 War or Dates 1�-.
J Place of Death Hospital, Institution
City, Town or Village .Scoakq � 4et‘ikyls Street Address �a /10 if&L
a Manner of Death[XI Natural Cause Accident Homicide Suicide ndetermindld Pending
Ll �4-� Circumstances Investigation
ti Medical Certifier Name A Title
RI&5 A-- 4,e�� to
Address
&// Nuic(h S, do izal6g 4Jpe,kV, Air /0A-6
th Certificate Filed District Number Register Nu/nber
Ci , Town or Village � 3i.iii 6 Sb I 7 7
Burial Date
Date /� (�
&/a // Cetery or Crematory
LP i NE V J Pcd C Jee/ �e 1
❑Entombment
Address l
<' Cremation 07/ aua�-e t i ctd Jaee�Sbuic� / /V P) 54/
Date Place Rernbved
Removal and/or Held
C: and/or Address
l= Hold
t1
0 Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iigiEi Permit Issued to ► Registration Number
Name of Funeral Home Loni C<<S�i tivie u hula/ (ard---,- NC _ 66,5(/4
Address
/O g Imp )) Zvi, 0 11.eal-ng �Sp e i k)q s, ?Y /cRk(O� .
Name of Funeral Firm Makin0Disposition or to Whom
1 - Remains are Shipped, If Other than Above _
2 Address
in
Permission is h eby g anted to dispose of the human remainsdecried abe a indicate .
[ Date Issued (� Registrar of Vital Statistics `--., r.
(signature)
>< District Number 45 D( Place 2it/Dg4' ,)t1t7,15 r I Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (P(z (1b Place of Disposition flea-d (riemeto i
(address)
(section) (lot pumber (grave number)
,e of Sexton or Person in Charge Premises (�'`°i) .t r t Art ii,
( ase pr
'ire (12- Title Criftwrrit
(over)
2004)