Towers, Leo e
NEW YORK STATE DEPARTMENT OF HEALTH ke it(
Vital Records Section Burial - Transit Permit
Name First Middle ` —' ast SRC ,a ,
•
L 'c o /"T
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Date of Death Age If Veteran of U.S. Armed Forces, 1
D.l i( /A, tt g6 War or Dates ( 1�{1— Li-7
}-: Place of Death 1 Hospital, Institution or
: � own or Village c�TN?� Street Address ,SAr�4- �1.. 140 `4
er of Death Natural Cau A cident Homicide Suicide Un termine Pending
U# Circumstances Investigation
tu Medical Certifier Name
Title
0 Addi ' i-c� d?-7-i--ik
✓iiJ• 1 C.A . . clqfs4t.-IPyi N c(66
r Certificate Filed District Number Register Number
ii
_ own or Village �Af*Ta S
■Burial Date J i Cemetery or Cr tory
14 1 l- [ X i:A i ry e.VI -c-ma's Cr C.+v+�4r
Entombment Addre
Cremation btv.LeAS9 ,,Lr �,,, Yaf/L—
Date . 1 ) Place Removed
❑
Z Removal v and/or Held
and/or Address
E= Hold
4
0 Date Point of
ti El Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to E.,,,t.
Registration Number
Name of Funeral Home C,AS4W-e- r. C fL.u.grii -14e- . 0o 'l` fl
Address / c h e r-,... o t f - . )`t').1�
i Name of Funeral Firm Making Disposition'or to' Vhom i
Remains are Shipped, If Other than Above
Address
CC
til
` Permission is hereby granted to dispose of the human remaiqte9crib abQ ' dicate
Date Issued trill J -(% i l Registrar of Vital Statistics (( i
(signature)
District Number 45W Place SARATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
al Date of Disposition Mt,litt,04 X.Place of Disposition ;. J ) Ce#401►I.
2 (address)
II
0
CE (section) (lot number) r (grave number)
Name of Sexton or Person in Ch ge of Premises At►sk Jd
2 (please print)
irn Signature Title CPI . rn
. (over)
DOH-1555 (02/2004)