Veillette, Ronald NEW YORK STATE DEPARTMENT OF F I v r
Vital Records Section Burial - Transit Permit
Name First MiddleLast Sex
2D 0C et Mile__
Date of Death�� J
Age ,v If Veteran of U.S.Ar d Daces,4 if War or Dates
i_ Place of Death Hospital, Institution or
Z City, Town or Village /-/O �l' � h lCS)- Street Address FT/her AIM. f�,7✓t
w Manner of Death{Natural Cause Accident Homicide Suicide Undetermined Pending
%%``'� Circumstances Investigation
W Medical Certifier Name Title
G Vr, ? v i sQ(Jirven IMP
Address l_ .F
q N w L' Q((/n5 k) AJ Lf /78Z
Death Certificate Filed r District mbler Registpumerb
City, Town or Village /6 Chesf�� s6.-2-
❑Burial Date Cemetery or Crematory
❑Entombment 2/2-2" / ( ( 2k- - V l ed Cf.('m9 y
Address�` 1
Cremation (.4)t.) , k e/ 0 v c(4-2,5 0-�y
Z Date Place Removed/
Z I 'Removal and/or Held
2 and/or Address
cn Hold
0 Date Point of
u) I I Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home4/ i(,� �C��t� rii Gad-,s---
Address
3 K60 N1c, n sf bley-e,rns. -� Ay /z ._c
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
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a
Permission is hereby granted to dispose of the human emains describe ab ve .1 indicated.
Date Issued 2)i i / (( Registrar of Vital Statisti � , 0) nature)
District Number Place -7 ( GCS � ( es ki wi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fr P
ILI Date of Disposition ;cep al toil Place of Disposition RV 0,,,,,.i CrIA.Nc 41 44..
W (address)
Cl)
w
(section) a (lot num (grave number)
Q Name of Sexton or Person in Charge of Premises f,l}L ,,- b1
Z I(please print)
W Signature Title CR,i311 4-
(over)
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