Paris, Richard NEW YORK STATE DEPARTMENT OF HEALTH
45131
Vital Records Section '" Burial m Transit Permit
Name Firs 4iddle 1 Last Sex
t ch a,�-6rR t3-,5 FAN Var.i s I-1
' Date of Death Age I If Veteran of U.S. Armed Forces,
�;>_,, ag 113)2.0 Ile 85 1 War or Dates / 9 J )-- / 93 V
Place eath Ai-quilt
_ Hospital nstitutio r
• Ci Town Village ILEt N�(�l Q Street Address le4 as hi(i. Tan Cen4er
cl Manner of Death oiNaturat' %use O Accident 0 Homicide O Suicide Ir Undetermined n Pending
Circumstances Investigation
uj• Medical Certifier Name n 1�S �� � Title
o fib , / II ,
Address
N r1.-G L tf
be
<= Deat icate Filed �^ V Dis"trict N
ar Register Number
City Tow�jr or Village 5 G 1 51 3-j
OBurial I Date Cemetery Cremato
(Entombment cP Yin �40 rl-J�r I), .
Address ��//}} ,( r
rem ation U 01Cb - ICE a L.,etc.-us-6 /V
Date Pla6'e Removed '
2k E Removal and/or Held
. and/or ' Address
Hold
Date Point of
OTransportation Shipment
a by Common Destination
Carrier
<'O Disinterment Date Cemetery Address
=O Reinterment Date 1 Cemetery Address
Permit Issued to `� Registration Number
Name of Funeral Home 1 A/--\C-_r TL;\tcc- \ HDc'c\ . "�L.11 jL-
Address
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
CC
LLE
Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued Registrar of Vital Statistics ,fin.
IS /t. (signature)
District Number t�7 Place W 1 Vt� f fu
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
mit Date of Disposition g f N/6 Place of Disposition Raw./ a -
(address)
i (section) J (lot n ber) (grave number)
0.
tz Name of Sexton or Person in Charge of Premises AttJttioli �f1
SignatureZ (please print)
Title
(over)
DOH-1555 (02/2004)