West, Mae NEW YORK STATE DEPARTMENT OF HEALTH -P g72
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
rn 0.4 C C.A..S<.,4
Date of Death Age If Veteran of U.S. Armed Forces,
><' ) J )3\)b 1 p t War or Dates Y-)) c
'+ Place of eat Hospital, Institution or
City, Town or Village"J,s37vY- Street Address a r C�u '5\51 54, -,�
Ct Manner of DeatNatural Cause Aeident Homicide [l Suicide tit �Undet fined 'ding
Circumstances Investigation
iti Medical Certifier Name Title
O - 3 %--) -•,-.v.70-..,,- 1...V.).,:N-4---h---i-r(4-4,-, 1^71.---i ,
Address
Death Certificate Filed District Numbe _ Register Number
City, Town or Village ) =) ) C _
><i 0 Burial Date / ) Cemetery or Crematory
[]Entombment , ) Ys) 1 si s mac. ✓-icy �r�r2,--,_A-r,�
Address
>< Cremation (.v4AC f 1,> v c ,5 11-a- (N7 Y
Date Place Removed iollp
❑Removal and/or Held
and/or Address
LT Hold
? Date Point of
0` Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
IIIii Name of Funeral Home IRC ,., ��.,_,Q., ..,w.c .,_,j ,Q s sl'):3
Address
Name of Funeral Firm Making Disposition or to Whom 446
• Remains are Shipped, If Other than Above
;` Address
Ir
ilk
Permission is hereby granted to dispose of the human re - s describe above. a ' dicated.
is Date Issued 1Q k 4~1 Registrar of Vital Statistics }6
(signature)
District Number „G �� Place 1 ��iK 4,-_\ YE) t
I certify that the remains of the decedent identified above were disposed of in accordanceNvitti this permit on:
Z
Ili Date of Disposition /7 V/to Place of Disposition2/3'7Q j� C�t .) e cep'ic,:k y
/ (address)
itit
CC (section) 1 (i.. umber) (grave number)
t Name of Sexton or P rs► Char e of Premises J AL / �ayl 6a GLi. .2
✓� r"`._-- (please print)
14
Signature /iiill.--/j C f Title L' 1444- v'
(over)
DOH-1555 (02/2004)