Smith, Stanley NEW YORK STATE DEPARTMENT OF HEALTH if 1 411
Vital Records Section
Burial - Transiermit
Name First Middle Last Se
� �''I /e DIAC314e, o/I./ I , CIF./
Date of Death J Age If Veteran of U.S. Armed Forces,
n3 -a3 --,20// 1 77 I War or Dates /9: 49:cs "
E• Place of Death I Hospital, Institution or
W City, Town or Village 6.-keiS X& I Street Address c /f ei ,.//i , s 'i7 --/
W Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined D Pending
Circumstances Investigation
W Medical Certifier Name f
Title
ddress d -
Death Certificate Filed District Number Register Number
City, Town or Village I
OBurial Date I Cemetery or Crematory
❑Entomtxnent D3 -`o1(/- // ! n� V,:e'wi ✓e l)—�.l
Address
Cremation •
Date i Place Removed
Z❑Removal E and/or Held .
2 and/or Address -
tiq Hold
O Date Point of
Transportation Shipment
3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1:1Permit Issued to
l I Registration Number
Name of Funeral Home 1,4 c,,/(dal d , _iSca..ec \u nc'c t -1 iAo(ram 1 0) I `--i G
Address
11 La- ye e_ S. C�2ute lSoury , 1vev.-1 `jot- L._ 12s30,-1
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2, Address
it
ut
Permission is hereby granted to dispose of the human remains descri ed above ind- e .
Date Issued 03 2 20// Registrar of Vital Statistics
� (signature) •
District Number SC/ Place 4 v /A. ,y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-4
til Date of Disposition S "Z g•‘‘ Place of Disposition RL 1lt,,s 61m-e l)nfur•.-
(address)
w
re (section) 4 (lot number) (grave number)
CIName of Sexton or Person in Ch ge of Premises 11 r. Se,,-c tt
2 (please print)
!if Signature 1 Title C E M ii-I I7R-
• (over)
DOH-1555 (02/2004)