Dodge, Harold e
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permi
Name First , , Middl L st \ Sex^�
Date of Death Age If.Veteran of U.S. Armed Fa( es,
l
OSS (01 aot t "11 War or Dates i Lr3
Place • Beat � � Hospital, Institution or
Ci , Town .. Village j Street Address
Ma - . Death-NaturaIZ `�use ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
iu Medical Certifier Name Title
Q t: ) T ► et' 4sALcc 1'''i ,D .
Address }� �\
6 1 s t/i"- o' .1 �(`r1/^,—,,-c_G, /A/ ( 1.- 3 `t
Death Certificate Filed District umber Register Number
City(TowQor Village / (v Le_ S-7 c 0 `t)--
❑Burial Date (J Cemetery or Crematory
El Entombment
? / ( t / a, 11 i n CV;e t.., L e-,A1��.�r
Address
aCremation • 0„),,,.c__<,,,s p,� f,J� j r f
Date Pace Removed
❑Removal G and/or Held
....� and/or Address
L": Hold
Cl)
O Date Point of
tad 0 Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
•
Permit Issued to -.0___
Registration Number
Name of Funeral Home , -�,t 5,,,,, ,e -,��rk l_ �^�r l--<=,- OO 1 'g
Address 7 r
5Lc_r.,a,,' Ave C_ter. I !'`d )--1_
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.Address
I
to
fl" Permission is hereby granted to dispose of the human re i 's described abo indicated.
Date Issued 1/ l 0 a o 11, Registrar of Vital Statistics -1 9.__,.)-•
(signature)
District Number 7�U Place 7Le..),1 6 r gy(--e__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t:U• Date of Disposition I,-IL-(( Place of Disposition Pi^Al0") erw- t tot•-
(address)
' Ili
VI
CC (section) d(ss.
Plot numbef�r``'' (grave number)
Name of Sexton or Pers n in Charge of remises Alr- Jt,+,r1
Z (please print)
Signature L Title ON: h 4.
(over)
DOH-1555 (02/2004) •