VanDyck, Grant ,c1- -21
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit ermit
NanN First Middle r\plc Last Sex
Date of Death Age If Veteran of U. Armed Forces,g e F ces,
10—\5—Z01,(9, co War or Dates 00
rI ce of Death Hospital, Institute nor
Cit , Town or Village lep5 RI.S Street Address lens Falls Spi't
Gi Manner of Death Natural Cause 0 Accident El Homicide ❑Suicide ❑Undetermmekl ❑Pending
W. Circumstances Investigation
tu Medical Certifier Name Title
Vt C-vnnrn� � $4
Addr .kAS , Il S JVA A/
Sae.alh Certificate Filed - 'District Number Register Number
Citj Town or Village 6 IPy s I-tx,l IS 5C O I .."---c? 7
❑Burial Date .. emett or Crem tory
❑Entombment ID - 17— Al 1 ill- N( Q 0 rerna o n
Addreskm
'Cremation CA u( S)-3 k'f\j
Date 1Place Removed
Removal and/or Held
1— and/or Address
Hold
Cl)
Date Point of
❑in Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to --� I �� ) c-
Address
Regis Number
Nameof Funeral Home 0r�4 Chu..rd St Lak A 12.8%
Name of Funeral Firm Making.Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
cr
t:U
P" Permission is hereby granted to dispose of the human mains described a ove as in cate .
Date Issued p 1 / ioKi. Registrar of Vital Statistics
signature
District Number Zoo / Place _0_{_4 ��
I certify that the remains of the decedent identified above were disposed of in accordance th this permit on:
Z U.-4
Ill Date of Disposition /oJI1 hi, Place of Disposition 601,4 raw.,
W (address)
CO
C (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises r., r Sty4tIf
« (please print)
• Signature et Title Cei5 Art- L
(over)
DOH-1555 (02/2004)