Purdy, Eugene gC)1-
NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section �; Burial - Transit Permit
Name ,,First Middle last Sex
1= t�q-e, �t& cl./ Ma 1e
Date of Deat' Age If Veteran of UIS: Armed Forces,
1 I — r3-" 1 11) -7 . War or•'Dates p
I Place of Death Hospital, I nstjtuu ion or City,c ow or Village 4 (ri,d I-e_ Street Address I Gj 73 Hadley' Pill I
12 Manner of Death i Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
tu Medical Certifier N.Name Title
a l -e,or -e & n ► apkiv NJC
CAddres` '� ,
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l
Death Certificate Filed District VIA Re ster Number
City,Towbr Village -1-1 0 Cl I
te oemat r
❑Burial Date � mery y
<>['Entombment I I— -7 ^ A LP Y1, V\,I e-t.�1 _-n'icto j
Address
iCremation WQ_JI11S Iall A--q
Date Plate Rem ved
Z Removal and/or Held
P..❑and/or Address
I= Hold
In
0 Date Point of
t: Transportation Shipment
Gs by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home3 �E �' ,fir ( 1-,-0I I i'1�; (��I I
Address
M4 0.-hu.r—.h St, LJK Lik212,1 M1 1 .3 L-1(0
giH Name of Funeral Firm Making Disposition or to Whom
li Remains are Shipped, If Other than Above
2 Address
1X
ill
P:` Permission is hereby granted to dispose of the human ' s described above as indicated./
RE Date Issued I t—�— t (4) Registrar of Vital Statistics rem �j7ay 'p 5y Gf'//
(signature)
District Number i/,55? Place town of I4c 4 /e4
/
''' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition ilJt/i6 Place of Disposition eavo,,, C"'"'wf`r.'"
(address)
a:
(section) i (lot number) (grave number)
f Sexton or Person in Charge of Premises [ Ar;� r Sf�gt tts
�r (p ase print)
et Title (Of 61114
(over)
4)