Ward, Harry ,
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial ® Transit Permit
Name First Middle Last. 1 1 Sexil
ia,crki Robe ward
E,:::: Date of Death Age I If Veteran of U.S. Armed Forces, 'eS
$11311-b(6 1 g 1 1 War or Dates
I Place of Death Hospital, Institution or
Z , i r r Village f- t. Ann Street Address /2 J e (Jr-e-ct i Road
® Manner of Death 7j Natural Cause ❑Accident n Homicide 0 Suicide Undetermined fl Pending
R Circumstances Investigation
W Medical Certifier Name Title
0 Pa. araz Porirort
Address
1 V OP 61kic CEOrk2, aCt45 fiT,Lc N'.. 177°1
Death Certificate Filed I District Number Register Number
City own r Village F;-. �n�1 3,-
171
Date Cemeteryor Crmatory
❑Burial i C35 I N 5 12p1 La P fu..,�Ie0.) C mct �ry
Entombment Address
` : NCremation QVe.P11,5bU'i-i r Ail 1 24Oti
Date Place Removed
Z Removal and/or Held
l2 C and/or ` Address
I Hold 1
0 ` Date Point of
pri C Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
E Reinterment 1 Date 1 Cemetery Address
Permit Issued to Registration Number
>` Name of Funeral Home \.\kt'1e=.'1-- ;,•L,ZAA HD cc k- C_-11 �-,0
t. Address
It LeSa_,I e\;_ S-k- Lac=,��k_:: 1 f ty IZ`l✓CtA
Name of Funeral Firm Making Disposition or to Whom
E Remains are Shipped, If Other than Above
2 Address
CC
w
Permission is hereby granted to dispose of the human rem ins described abo ifs'rid' -t
Date Issued . /tea)/, Registrar of Vital Statistics '��
(signature)
District Number _5%y Place /a 0 2 2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition If 17M, Place of Disposition g,..:0,....,
g (address
t #
(section) (lot numbe (grave number)
01
iz Name of Sexton or Person in Charge of Premises ^'<<r}4,' 31"`''
z d (please print)
Signature Title r11ZiPt41Vft
(over)
•
DOH-i 555 (02/2004)