St. Pierre, Bruce . . Z /� c7
NEW YORK STATE DEPARTMENT OF HEALTH -I Z?D
Vital Records Section Burial - Transit Permit
:: Name First MiMie Lea t 61 S
Av ce- PZ.e vS c�3, / 1 en 2 vs
Date of Death ( Age If Veteran of U.S. Armed Forces.
3 a! 4 ra 16 3 War or Dates ^(�P
14 Place o eath / I Hospital, Institution
City Town` r Village iO,,4J 4 li L 3" Street Address ®Q r,J �J oclb 41246 — C r
ty Manner of Death in Natural Cause ❑Accident Homicide p, Suicide ri❑Undetermined El Pending
14 Circumstances Investigation
Medical Certifier Name , / Title
L V i !�r!r'/,�/ /�' �Er s C c S O yc o.J eve
Address
Pa 6oy. "7 tOw4 tozv / .4) 1 Le (?)
Death ertificate Filed / > ( District Number_ / Register Number
'< City own r Village li . r''Q, Ler ! L`"�(" 3
Date I Cemetery . Cremato
❑Burial 31 Z ti /& I ri- LT (V/4,-,)
Address
:: Cremation U¢iC C,V‘-- a U B U
•Z Date _ ; Place Removed ' -
O Removal ; and/or Held
-- and/or ( Address
=7 Hold
CO
a Date Point of
1 E Transportation. Shipment
Ts by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date I,Cemetery Address
•
Permit Issued to t 1 Registration Number
- Name of Funeral Home 3i.'-1;,zz_ =�,,61i.r . 1 Y1:7 I Ct 130
Address
%i L/d n-=/,rL> >t� (>}��&z /.s r c.; /vy, /2.-0 k-/
Name of Funeral Firm Making Disposition or to Whom . ' •
Remains are Shipped, If Other than Above '
Address -
tt
;fez
Permission is reby ranted to dispose of the human r ains described�J above a indi ated.
iiw
'> cle
Date Issued h1.3 egistrar of Vital Statistics 4;kJt c.e d
(signature)
District Number S� l
Place ( �' OJ(,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition 3/l6 fit, Place of Disposition Si, �U (,+7•,of1,'ti..
2 (address)
ill -
CO
CC (section) /Jy(lot numb (grave number)
flName of Sexton or Person-in Charge o Premises r!I.n,ML. +i+�
z (please print) f
U1 Signature Title [WA rb -
- (over)
DOH-1555 (9/98)