Mosher, Andre t . k A rgo
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit ermit
Name First A Middle m Last Sex
744 A re_— 6_ ' `o S 2
Date of Death. Age If Veteran of U.S. Armed Forces, '
77 7/a0/6, 5 I War or Dates ` -'
1 } , Place of Death Hospital, Institution or
Z City. Town 0 illage �Pr\ Street Address all ALtirct Ave-
0 Manner of Dea VA Natural Cause 0 Accident `Homicide Suicide Undetermined Pending
—Circumstances —Investigation
W Medical Certifier Nam% Title
4 1'!7cA1e. ✓
L S, ,I',cam• toil
Address
Death ate Filed r District t fimb / Register Number
City own illage /. -1.-- 4 S3
Date Cemetery or Crematory 1
_Burial 77/ ( as/G ,tcV;c..," 6-4-4.4-ar
I ^Address
Cremation �A- c;,,s:.mot, ) Ale ,�, i,>/it
Date V Place Removed
Z — Removal and/or Held
and/or Address
Hold
O Date Point of
O _Transportation Shipment
E by Common Destination
Carrier
—
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to _ Registration Number
Name of Funeral Home _ ___.,ts,,,,,,r� - ;:t4er4( i--F,- .1.'t.- . 'oy-`t1
Address
Aer.. ,4 6,.. ,�; fobs?-
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2 Address
w
a
Permission is hereby/ granted to dispose of the human r:- _ •:scribed ov: - •t•cated.
Date Issued 7t !r / .,/6 Registrar of Vital Statistics Ai/P
v"'•a �A r e) _ ,
District Number `r5 5 3 Place C. F - 1
— ,(/e._>J l e,T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
(•- ?Inc
W Date of Disposition 7/IZr/10 Place of Disposition me ti✓ !r+-tic—'
(address)
LU
N
CC (section) ie(1552tmb (grave number)
g.Name of Sexton or Person in Charg of Premises - v✓
Z (please print)
W Signature ell Title (itk M
DOH-1555 (10/89) p. 1 of 2 VS-61