Tucker, Carter li
NEW YORK STATE DEPARTMENT OF HEALTH VI
Vital Records Section _ v Burial - Transit Permit
Name First C a r fe r_ Middle Last ickck Sex H
Date of Death 0Age If Veteran of U.S.Armed Forces,
�av l i 1(� c�,n War or Dates
H e of Death - - -
city, C fen S Fa //s o pita al. _:s . . Ci Le n s F l/S -f U.sp+o
la W Manner of Death atural Cause Accident Homicide Suicide Undetermined Pending
l•+L-�` Circumstances Investigation
W Medical Certifier Name Title
CI se coombes Hi)
Address
98-30 50, wesfern e J shcc r oily la&
-th Certificate Filed C' �Q `1 S ' District Number 1 Regis r,l uber
■Burial Date 0 J 3//ao t J remator� , /
[]Entombment I �/�e V (to 1,0 Cre ma_fc'
Address
$Cremation a KLLker id. , autznsbu,ry> is Sea/
Date Place Removed
02 D Removal and/or Held
and/or Address
In
Hold
0 Date Point of
i ❑Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1-ic no,"d .er uncr cd Urz__ 0 I 1 Sc.)
�
Address ..___.
li LanyQ+ie- S . , C uce lixAry , tie yor-1L 12 c
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
CC
ILI
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued < / 1/ / £ 1 Registrar of Vital Statistics � v I1/4)
e(signatur
District Number 5 6 0 i Place 6 ,s I ts iv t�
7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLDate of Disposition /-t.-- let( Place of Disposition ? n e.u 1' W Cr-e v-t_�kt,P I...r psi
L (address)
tlY
pCC (sechon) (lot number)) (grave number)
Name of Sexton or Person in Charge of remises 1 ►+-%crtt�y Qry yiP1k
�". (please print)
ili
Signature 4BTitle C r"c►+-10 yr r 4 S54
(over)
DOH-1555 (02/2004)