Langdon, Brian NEW YORK STATE DEPARTMENT Of HEALTH
Vital Records Section Burial - Transit Permit
Name First Mi dle Last I Sex
i3r i UYl / //C/> vs'"[� t-�`r�� _DY1 t�
Date of Death Age If Veteran of U.S. Armed Force
Cb\ 1 i ci 12.Ot LO 25 W4r orDates �/
gi Place of Death CHosDitalrlhstitution or
,t►y own or Village GI ens F01/4\,S' Street Address G\tns ra 11S iO. i*a,
Manner of Deat Natural Cause 0 Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name `5--- 6 Title
/, /24 c r111_6rii /Lb
<ii Address gi
/o r �� 0 Fi-u-j `Death Certificate Filed District Number er qr
Etaglik own or Village GI Fct\\s
Date / Cemetery or rema or� j Of
ElBurial / Z( /( 4 r /.J IC irk)
Address
Cremation UM_Ll ,/ ,Vj �ra 6 uJ►t-
Z Date Place Removed
❑Removal and/or Held
—• and/or Address
b- Hold
Q Date Point of
vi❑Transportation . , Shipment
a by Common Destination
Carrier
ii
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
RPr ti�5 NC- Oil
Name of Funeral Home / tion Number
PermitIssuedto Registration
'> Address / 3Q
If L09 L-) ftj'" Sr. 6u / s-a ord
/ 1.
<` Name of Funeral Fj m Making Disposition or to Whom i -
Remains are Shipped,,If Other than Above
sa Address iti
0
'g Permission is hereby granted to dispose of the human remains described above as, l
indicated.
: Date Issued )- l Z0(i 6 Registrar of Vital Statistics �„�7c,� ..�;.Q„ (1A.1-" U
iai (signature)
ffl
iN District Number 60 I Place (7 -,Q-,rc Vc.4,1 \ci / ts-) (I)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I/21/16 Place of Disposition 471Aiz..% ( imA. O(.
2 (address)
W .
u)
CC (section) Alpt number) (grave number)
0 Name of Sexton or Person-in Charge of Premises /4 nsio416 �g nr
g (please print) '
94 Signature l/L Title liZtillipt
- (over)
DOH-1555 (9/98)