Ogburn, David •
NEW YORK STATE DEPARTMEN OF HEALTH ' It g 6 1
Vital Records Section Burial - Transit Permit
ref'
Name First Middle Last Sex
i>C,\)►cl I� .� G burn I�
Date of Death c„Age If Wigan of U.S. Armed Forces,
1 l aq I o` t l p 5 S7 War or Dates NO
I`- P ce of Death ospi , Institution or G Ipls Fo�LaL p i+m.1
W Ci Town or Village G Sj\rC c Street Address I Of) 'Gu J
kL "i(-e 4 a Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ri❑Undetermined Pending
111E Circumstances Investigation
ta Medical Certifier Name Title
Pa,c6 (each man 1 0.
Address ,, r
3 71 `VV 7 HGLCAr1 S4, Q1fr J S NI_ 1 Z 5
th Certificate Filed �� District Number i r '�.J Register Number
Ci Town or Village G I en S � F 1 0�
['Burial Date ` Cemeteryor Crematory
❑Entombment i a_( °1 I Ile pin-e vl P L i C re_fi IQ JOr'
Address � �f G
[Cremation ( OX-{ Imo. TUfaiwtoL(. L ii q (a s'cril
Date Place Removed G
2❑Removal and/or Held
and/or Address�
U) Hold
O Date Point of
U"a Transportation Shipment
Es by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 El Reinterment Date Cemetery Address
Permit Issued to �- Registration Number
Name of Funeral Home t ie r t-�r e(--cx\ HO cn t- C t 1 - C)
Address
Lct 1 e - . .te ,sue 7 , Ny 12 01\
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tii
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I 2.4 z12_0 ►6 Registrar of Vital Statistics �v.
(sign re)
District Number 5 O ) Place G Iszfv-s Tel 11 s,W y'
` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U Date of Disposition ILI b III, Place of Disposition /LU{� (r 'a!_—
tU
(address)
i
CC (section) i(lot number) (grave number)
fl Name of Sexton or Person in Charge of Premises c Asja E,- J iit
2 (ple se print)
LO Signature U` -%1-- Title (KC AMC_
(over)
DOH-1555 (02/2004)