Sammis, Virginia it
NEW YORK STATE DEPARTMENT OF HEALTH ` ) (qo
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex ,
V t �C3In, 1�..:,�\;4n ,mks �
Date of Death Age If Veteran of U.S. Armed Forces,
O / a 1 ' a p 1 Lo 9 o War or Dates
F., Place o 9 ath Hospital, Institution or
j City, Sp or Village Gcc.if u t A€_ Street Address y ne �0 use
W Mann- • Death 0 Natural Cause 0 Accident ❑Homicide Suicide/ 0 Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
t3 G le r Ch ona , M D
Address
PO 6 bX a.9 -T;wrv-Aer c N lag83
Death ificate Filed r 'Distrr t Number Register Number
•City, `►or Village BR1e t 11-e- 51 J`�Lo I
1DBurial Date Cemetery or Crematory
['Entombment AddressO9 1 Q' ) ac t L P‘ne V L f.,.,) Cie MQ}Oc
OCremation Qoee(\svA kc j N y
Date Place Removed
f ❑Removal and/or Held
and/or Address
F_- Hold
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O Date Point of
tl
❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home +t VD>( R eTt n d1 g-a 1
Address
11 A\aonKLn 5i-. TTConcXoCcc. Ny 1a38.3
Name of Funeral Fir`ri Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Z Address
tr
LU
44.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I a oZ pot 1P Registrar of Vital Statistics cL(Ws
(signature)
District Number 5 r13 p Place —7lon 0-f 6-ran v \\.e_
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition Vtro, Place of Disposition PA B &i/ Gr-4. y)
2 (address
W
CC (section) t ,,,,(lot number) (grave number)
pName of Sexton in Charge of Premises f k✓+ Cla-✓rr. 4'
z (please print)
tt- Signature Title £! - s •io/
(over)
DOH-1555 (02/2004)