Webster Jr, Ernest NEW YORK STATE DEPARTMENT OF HEALTH SL O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
R ✓L=1'r �% ' ' 97-4f, .3-rR, M/II C-
Date of D ath l Age/�/ If Veteran of U.S. Armed Forces,
/�G76/�e)// CO 7'' War or Dates
- P of Death Hospital, Institution or �1
LiJ ity, own or VillageG`J S'F, l �' Street Address (�-. �l✓-S' �/3.L G�/TO-2 ll
ri nner of Death Jf Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
U Medical Certifier Name Title
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Address 6/,0 2 f/1LZ ,
/O� ��0�1� s T� �/
Death Certificate Filed District Number Register Num er
City, Town or Village<�/1/S' f/ LL 2 �6 O / ��,
❑Burial Da��/a` 'o `/ Cemete
ry or Crematory
�l/f �J c e mg/ 2R/Cf I1❑Entombment Addes JgCremation 7 eA/ D f 4,4/� 2vs' 61r(,q\ 'y. 1 '44
Date Place R movecd(
Z❑Removal and/or Held
and/or Address
Hold
O Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Nu er
Name of Funeral Home)77JgS'0/,/ ff./A/LW/9Lr Hd �" O/// %
Address
�o;O3ox 72Fd T" / A/Y /ac' 2
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
IX
ILI
CL
Permission is hereby gran ed to dispose of the human remains described above as indicate
Date Issued/// //Registrar of Vital Statistics CA-k}r-%
(signature)
District Number Sj 6y Q/ Place C/ fry p {�' gr ,4LW2 FALL f ,VXj
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU• Date of Disposition #Jou toi 2ot‘ Place of Disposition ?,.auut Cr iwa{oiikm
s " (address)
In
0
CC (section) (lot numb (grave number)
0 Name of Sexton or Person in Charge o Premises ���tit�A�`+f t�n�H
ri► 44 I (please print)
iii
Signature Title (eon Pilot.
(over)
DOH-1555 (02/2004)