Dangrade, Wayne it 3
NEW YORK STATE DEPARTMENT OF HEALTH �1
Vital Records Section Burial - Transit Permit
Name First a Middle Last Sex
PO/9-y jI/ 04No�' /4- r_ 044
Date of Death Age If Veteran of U.S. Armed Forces,
7 cf' .2Q �/ ;5.2_ War or Dates /47 77( -- if s
}- Place of Death �;- Hospital, Institution or" /
City, Town or Village - a f/ 5 Street Address 1 ri-f ' 55 it5 � ilA
iii0 Manner of Death Natural Cause [_]Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
t Circumstances Investigation
ill Medical Certifier Mme� ����,- w- ' Title��
MI ? N
d res
QQ j, rreli?r 0 aa
Death Certificate Filed / r C District Number Register Number
City, Town or Village 6L%."IU 5 / iL S .6 6 0 3a-Li
['Burial Date C metery_or Cr atQry
7 / - .Zd// j 4,1( Vs i-W
'i ['Entombment Address
lEa emation ( a r. --tti60 it y /U y
Da }Slace Removed
pr
Removal and/or Held
9F and/or Address
H Hold
CO
0 Date Point of
L` Transportation Shipment
a by Common Destination
iiEii Carrier
: :: ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to �/�� Registratio Number
Name of Funeral Home (-d 4-tI I /r/�� F. i elo-ri 9
zi Add ss _ /
mei Name of Funeral Firm Making Dispositiorf or to Whom
.f .. Remains are Shipped, If Other than Above
2 Address
ir
t
Permission is hereby granted to dispose of the human remains des� ri ed abov as in ated.
Date Issued 7 // -4Q// Registrar of Vital Statistics �"�'tile, - ,i-
(signature)
iig District Number 4,,i
Place G 40-5 ; ti X.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iti Date of Disposition 1-iZ-i I Place of Disposition Pig U w,; o04-ti,.,
W (address)
in
i (section) A `(lot numb (grave number)
Name of Sexton or P r on in Charg of Premises 0. P ,4ritt
Z (please print)
Si nature Title Cite m '-
f
(over)
DOH-1555 (02/2004)