LaCroix, George NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section Burial - Transit ID ermit
Name First __Middle Las S ;
CgbiZ4t- i26-A� .:bra" ►201
Date of Deat A e If Veteran"5f`U.S. Armed F rces,
Ii/9 16 War or Dates ,JJ/B
1— Place Place of Death Hos•ital Institution or
E:C_LOTown or Village GThtOrjs F647X-S Street Address' 6 0 1917 Eh6,J Ail"
0 Manner of Deatht'niatural Cause ❑Accident ❑Homicide ❑Suicide ri❑ Undetermined ❑Pending
Ut
Circumstances Investigation
at Medical Certifier Name ,�. ,(� Title
ta I //-1 O> / ILIA p CtcS},...0 ..1 Lv —
Address 40i
S-- 2 ,�V I C. - p V
th Certificate Filed District Number Register Numb
City,)own or Village k1:e',oS /- 0-1, S L(Q O I �,
❑Burial Date Cemetery a ..Cremators t
//El Entombment //O 7/ 4, ' ' t " i�J
Address
;:::;;: emation (7) k.)}3'7L L"k.-- Ycj Q 0 C r.�_z Q u 17
Date Place Removed / A/
Removal and/or Held
and/or Address
- Hold
C
0 Date Point of
CL
❑Transportation Shipment —
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to 1 Ft),,J
Registration Number
Name of Funeral Home 11, 0-,L6ti,___ UAiy2_ 1-7U' 01 13 O
Address
/t L-1 cr & 0‘- -1-.�,C t
Name of Funeral Firm IKaking Disposition or to Whom
I-- Remains are Shipped, If Other than Above
Address
IX
tti
Permission is here y anted to dispose of the human remains desccrr'beed ab ve a 'n icated.
Date Issued r///d /� Registrar of Vital Statistics � r/ L ��
(signature)
District Number 70 d 1 Place C c tf,3 3 l-01_6, y
I certify that the remains of the decedent identified above were dispo ed of in accordance with this permit on:
nI
iii Date of Disposition /litil (, Place of Disposition .44c)L I rtr. y�-Jf•-%,
2 (ad ress)
iii
(section) )/(lot number) (grave number)
Name of Sexton or Person in Charge of Premises /L� jV'7
z (pl ase pririf�
Signature la aTitle C!if('' i Itk
(over)
DOH-1555 (02/2004)