Ethier, Andre NEW YORK STATE DEPARTMENT OF HEALTH N., 31-
I V
Vital Records Section Burial - Transit Permit
Name First And� Middle f L� S��
Date of�D�th�f } // Age If Veteran of U.S. Armed Forces,
A 01V- / 7, 05 0 l �� War or Dates
.1 P e of Death Hospital, Institution or
C y Town or Village G L& t� fc,I/c Street AddressI/WIli
nner of Death FNaturai Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Vending
Ili .0 . Circumstances Investigation
tu Medical Certifier Nai) Le/
e /� `/ ,, Title
II a/) �C/c ✓�
/ Addres. / //� 9 7:
/ to/ t7/ - 61,,,L.2....s,
4. //_ _/�/ off--(43,d/
im D h Certificate Filed ,� District Number Register Number
ity4 Town or Village ��27,1 t /// �6 o/, (j—.3
gi ❑Burial Date _
/ Crematory,
mat
�' L eiti ,iji,)_e / J C /,,, a4-�, /"r 4, e,//l ip.❑Entombment
Address ,)
< ' remation Ul et ` - ,,V CV/J-e iX✓// `�//,).., �
Date Place Removed
❑Removal and/or Held
{4 and/or Address
F_ Hold
t
0 Date Point of
L` Transportation Shipment
Es by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
10 Permit Issued to ��-- Registration Number
Name of Funeral HomeceVi ).4' C ,--7 69fkz&/'a/`�'- ,i C - GZ9/L/7
Address
Name of funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
III
P'` Permission is here gr nted to dispose of the human remains describ dab ve indi
li Date Issued //0/7 Registrar of Vital Statistics �i(
(signature) /
District Number/ Place , ( 0 Cf f // / Q
I certify that the remains of the decedent ident ied above were disposed of in accordance with this permit on:
2
ILI Date of Disposition NOV rt It,04 Place of Disposition t..4V'c'J Cri"et a(i1%
(address)
tu
cc (section) 01 itinumbei) (grave number)
Name of Sexton or Per n in Charge o remises IA\ f �rl4r
ase print)
jg
iiii! Signature Title Cb'1l riA- -
(over)
DOH-1555 (02/2004)