St. Louis, Leonard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section it
41114Burial - ransi Permit
>r: Name First Middle Last I Sex
i = Leon \lrY3er:\- S.A-• L 00.1S I r1
mi
Date of Death j I Age I If Veteran of U.S. Armed Forces.
- 07 j 30 1 Z01 i0 I 51 j War or Dates U.i1Y1nOuJY1
ig Place of Death I Hospital, Institution or t-�
Ci ,Town or Village dens asks 1 Street Address G�C "S bays AAbspAta 1
Manner of Death Ni Natural Cause Q Accident ElHomicide Q Suicide ri❑Undetermined ri Q Pending
Circumstances Investigation
Medical Certifier Name Title
Al frrichca.1 Fo)1er (3hys;c;c�,n
Address `I
1 r)0 Pcar\ -rel-' G- - s (c,\ s , Al ►z!c,1
Death Certificate Filed District Number - = Regist
ER City.Town or Village j 1 GO) I.
Date 1
r�t Cemetery or Crematory
::::: 1 (Burial j DS )c> ) %O\VDr P YIP U ieL i Cw \aA-o,r-�1
j Address l
Cremation+
i Date _ l Place Removed T� y
2 — Removal i and/or Held
—and/or s Address `
rt/? Hold
0 ' Date Point of ,
gi n Transportation,1 ; Shipment
Fs by Common Destination -
Carrier
Disinterment Date Cemetery; Address
:::: E Reinterment Date Cemetery Address
Permit Issued to ! Registration Number
- - Name of Funeral Home L - --s:• -I — l ^r-
Address r-,
<< Name of Funeral F rn Making Disposition or to Whom :/ ' f ' •
Remains are Shipped. If Other than Above
Address -
i
Permission is hereby granted to dispose of the human remains described above as indicated.
( Date issued 8 1 r 1 Registrar of Vital Statisticsyy\sa
l (signature)
ig District Number �. r Place �o -v' S 1 I S , !V y'
l I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i it
p (`6 Place of Disposition ��u,uaw (446.---
2 - (address)
fill
-
� (section)(please print)
(fot pyt�)ber} 3 (grave number) -
flName of Sexton or Person-in Charge of Premises • C`l��,�%y�,
144 Signature Title aZE iViL
- (over)
DOH-1555 (9/98)