Touchette, Edmourd NEW YORK STATE DEPARTMENT OF HEALTI •
Vital Records Section Burial - Transit Perm
Name First - Middle Last,/ Sex
b-(,/r�0 tiR I 1- ouch e /7e k WE
Date of Death Age If Veteran of U.S. Armed Forces,
C-56, /'/ ZO/1 a V War or Dates )/es.. w tali-
,
Place of Death / Hospital, Institution or. _
City, Town c(Village fij/�"i 7 't 7/f 4-�- Street Address 6,2 /'�OG�i'7"fi'i 57lz 7
0 Manner of DeafFi2 Natural Cause D Accident El Homicide El Suicide Undetermined 0 Pending
IW Circumstances Investigation
in Medical Certifier Name Title
O /946141-'7 E,5 e.•-N/4hh
Address
Death Certificate Filed District Number Register Number
City, Town or Village ,S X 6 /rI
Date Cemeteryor Cremato
❑Burial /O -- / 7- 6/i
['Entombment Address
e u.ec,) /?4'�,i?/Z/U�i
:, Address Cremation y ,/l// /?5D c4
�l �Qt�,�-/cry, /td.�c:P c �'� �r�Slv�s+�
Date Place Removed
gIn Removal and/or Held
�=
andHold/or Address
Date Point of
0`El Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to _T Registration Number
Name of Funeral Home /SO c-! P`u�e/2 /'7fr''e �c / 9'
Address
,Ve, U� i/e ads 57izfC i, 4-0 hi/T 6.fir /i// /03 it 7
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
111
Permission is hereby granted to dispose of the human remains describ d bove as indicated.
Date Issued/7—/'9 // Registrar of Vital Statistics
(signature)
District Number 574,G Place ai u eeee. it, /� (er7
;_::;: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E /�
ILI Date of Disposition 'oils fit Place of Disposition .p,KU,,,,,) C it-N turti+�`
a (address)
ta
cc (section) / (lot numb,p (grave number)
ci Name of Sexton or Perso in Charge o Premises r r^ ... e.,retfi
z74 (please print)
-:,- Signature Title Ci?EP i 400-
(over)
DOH-1555 (02/2004)