Trowers, Venus NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle ____Last I
Ve ) tks E. . I ro j ( rx. - 'Y
Date of Death Age If Veteran of U.S. Armed Forces, . 4P�� -!
d 8I� Zo/Co "�Z War or Dates \
, P - e of tea /� / Hospital, Institution or
5 own or Village G�C/�SF.z//.r Street Address 1r ej s cii is Fa-in
12 Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide Undeterminc Pending
ti! Circumstar Investigation
iii Medical Certifier 1 Name Title
Address
l- 5o WarYen st-. G s F-IVs, NY iz
�D t,h Certificate Filed J District Number 3ter�r�
.ity Town or Village t/e'U A -/c c
❑Burial Date Ce. netery or Crematory
❑Entombment o�J22-ko/6 i/1� .Cr1/t�e-co C eyn
Addreji
iii;ii! Cremation 0-0-a-4r toi . ee,„_s
Date Place Remove
Removal and/or Held
and/or Address
t: Hold
C4
0 Date Point of
Cti
❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
!ilig❑Reinterment Date Cemetery Address
Permit Issued to ,> Registration Number
Name of Funeral Home (Y) K:on .t . pq 0/0 �
Address
00 f . o of- SG. Gars 1/(S' , ivy 12S-0 3
„. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t'I
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8/72/ l 6 Registrar of Vital Statistics lik.)C
4.„42 (A). --emsti--
(signature)
District Number 5 p i Place 6 (Qik".,S \,\s i Ai y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Lu Date of Disposition g 23J/22 Place of Disposition h O j-k c�) G , t
2 / (address)
til
CC (section) t (lot number) (grave number)
CI Name of Sexton r n i Charge of Premises ,I ��L/+4
2 (please print)
Signature Title 6- Pl -1-"..
(over)
DOH-1555 (02/2004)