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Edwards, Carleton
11 NEW YORK STATE DEPARTMENT OF HEALTH f , S� Vital Records Section Burial - Transit Permit Name Fir Middle ast Sex `: Date of Death A e If Veteran of U.S. Armed Forces, 111 I I l 1$1 l 1 '© War or Dates Place of Death ._.--. rr --- i Hospital, Institution or , City, Town or Village /✓t at- ll ii nth Sl Street Address DLL, Ul 0 Manner of Death 54 Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined Pending ua Circumstances Investigation la la Medical Certifier Name Title n Address Death Certificate Filed District Nu er Register Number iigi City, Town or Village 6-6 3 J <O� 0Burial Date // metery or Cremat/no�ry-- :< []Entombment "/b°L( I l I- rc ,_&4.-�.�"O�T 1-1"0,61517 Address �j ;;Cremation _�L Q& -Y a' L `'� Date Place Remov _Z❑Removal and/or Held and/or Address = Hold 01 0: Date Point of i Transportation Shipment L! by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Mi Permit Issued to Registration Number Name of Funeral Home-Ty\ , 13 , u�cC .4, - ' .2L4 - e_.' 0 i 01 Address 1 ; in_CLZ A- j -t-L . ca i °Y'd Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address iti Permission is hereby granted to dispose of the human remains escribedfJri� o indicated. Date Issued I 1] I do II Registrar of Vital Statistics :Lea' at- _ / (signature) District Number 6-6 s' C1(� � Place ` Y7 op �,,`1,,, v v- I certify that the remains of the decedent identified above were disp ed f in accordance with this permit on: lit Date of Disposition NaV t) I irl(Place of Disposition ty.N bfo �e�4GYtV.- (address) ill CC (section) (1 t number) (grave number) 0 Name of Sexton or Person in Charge Premises A,..4r' y 2r please print, AL rt Signature $- Title cue or„ C (over) DOH-1555 (02/2004)