Smith, Crosby it
NEW YORK STATE DEPARTMENT OF HEALTh i �1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6_YOSZ �o >' ,crn//i /C/
Date of Deat Age If Veteran of U.S. Armed Forces,
y 1/ 11 War or Dates 5-2 _CC
.N Place of eath Hospital, Institution or /7/ - ,�C�,G c/%'f
City, Town or Village /� S , 7/<- Street Address Ayp r,44/064s-e, ,-("��c(./
0 Manner of Death`�t'Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
lit Circumstances Investigation
iii Medical Certifier Name Title
1 1�p �_.r�, /41.
Address
11
3D?/7 L3/o / J / 151r1C- Ci�c,/V/r ///
iMii Death Certificate Filed Dtst t Number Register Number
(City)rown or Village-z4,7 77c
❑QUflal Date Cemetery r Crematory �
X.-2 t, 'e.„ ,,i .,-%e,/,,4 cwity
i:: ❑Entombment Addees 77
Cremation (Xiteel Si ✓ /
Date lace Removed
❑Removal and/or Held
and/or
Address
f
Hold
O Date Point of
t0 Transportation Shipment
6 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iiiQ Renterment Date Cemetery Address
Permit Issued to �� D Registratio Number
Name of Funeral Home /% /7a, L/ , k/ ,/civ-
,:,,,,,,„,
<! Address a
Z,12 y� ie, a(4Pev)s,��/Y, /1"7' " '9'
0,,,, Name of Funeral Firm'Making Disposition or to Whom J
1 Remains are Shipped, If Other than Above
• Address
III
Permission is hereby granted to dispose of the human remains described o e a in 'cate .
Date Issued Registrar of Vital Statistics /CG � L ,t.
(signature)
iiiiig District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k /'�
ILI Date of Disposition Nf-Zc►1 Place of Disposition -R�aI>z� C f'bn-s rlot.
(address)
Iti
CA
a (section) ► (lot nu ) (grave number)
L Name of Sexton or erson in Char of Premises G .Jtz .' %a
(please print)
9
Si naturet. 3/4 t^Title CRC it,<ai
(over)
DOH-1555 (02/2004)