St. Clair, John NEW YORK STATE DEPARTMENT OF HEALTH # 77 0
Vital Records Section Burial ® Transit Permit
Name First nn Middle Last(�``v' ( S )
J o1f,.� ,�C 0 r3v'n_�"_ �r , `_L,9i2 1 /782 r
:-:> Date of Death Age 1 If Veteran of U.S.Armed Forces,
::- /o�a.r// (d 9/ 1____warQrDates (9t --L9cF
i Place of Death _ ( Hospital, stitution r f_
i ��Ci Town or Village O(`L c,is F13- S trees ddress U'L e-„,s ` $"BLS
lVranner of Death Natural Cause 0 Accident n Homicide Suicide Undetermined fl Pending
la Circumstances Investigation
O.
Lu Medical Certifier Name Title l
Address Co Pay-bic C Q Le.51"), F - ,�
•-.th Certificate Filed l District Number ' egister Number , 7
0own or Village L c l',Js Fat Li l '" " D-zz✓
•Burial 1 Date Cemetery orCrematory/6 /Z
i / l l z: V i 61-)
❑Entomim i Address
AiiWCremation t 0 R1e 6,tit-- 1�--e) Q (-)c� s.� 7
Date 1 Place Removed
Z Removal 1 and/or Held
—and/or Hold i Address
CA
0 1 Date Point of
IL
C Transportation I Shipment
by Common 1 Destination
Carrier ,
_1 Disinterment Date Cemetery Address
Reinterment 1 Date ! Cemetery Address
>< Permit Issued to Registration Number
Name of Funeral Home jC'1" �L;;i'l ez.crx\ -\D fscl{-- C<i l ;,0
Address c
1aNI ,\ (
'<_ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CLPermission is h reb granted to dispose-of the human rer s des ribed abort as indioat
•
Date Issued ( , ' ' t; ` Registrar of Vital S at stics Z.� \ l2,' ...
(sign re)
If
District Number 5 i ( Place 1-8 k .a.._C-6 57 Li
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
r Place of Disposition 'f i cl V L VlQ i. "
1� Date of Disposition / /76 �/b p
2 (address)
th
(section) Ati (lot number) (grave number)
Name of Sexton or Person in Charge of Premises f' t ( i'"'°r0.
ease print)
Signature 1 Titled U -
(over)
DOH-1555 (0212004)