Hunter, Eric NEW YORK STATE DEPARTMENT OF HEALTH ` * 0 7°3
Vital Records Section Burial - Transit Permit
Name First Middle 0 Last Sec `
»- Date of Dea I Age I If Veteran of U.S. Armed Forces,
3 Jlob40 I '7 3 i War or Dates y 83 ( /'Z,•)a1.a,3
}M; Place of Dea I H titution or/
City, Town or - Mps F�,S Street Addres /D , /Ortri.12ez,(( 1j '•
tz Manner of Death jNatural Cause ❑Accident 0 Homicide 0 Suicide Undetermined Pending
�^l Circumstances Investigation
Medical Certifier Name Title
0 7—, I;oPP,.s /�1 �
Address etityw.sj� /J
I Leo/
i]:::],
ii3 Death Certific . d f District Number' Regfster t9 amber
City, Town r Village /)O.( ��il, j I . 9
e 3 (I� �/ � i Cemetery •r Crem�ory � ) )
❑Burial f 1 i,U,_,- (11 tom..)
Address /Le'0
`:.:Cremation� J�9?Lb� t`� q v�/i3�S'(,�
Z i . /17--
Date Place Removed On-70 a Removal and/or Held
and/or I Address
Hold
Q Date Point of
•
N Transportation, Shipment
al by Common Destination -
Carrier
Disinterment Date Cemetery Address
Reinterment 1 Date Cemetery Address
; Permit Issued to Registration Number
<I Name of Funeral Home_ __., ji?r[-,-2. 1=�,,,v11,;-,_. lt,y C. . 0i/30
Address / , '
crit, I , j 00.. Ail L Li az, Ay
•
; Name of Funeral F� Making Disposition or to Whom f r G� `)j •
Remains are Shipped. If Other than Above `�
Address
f
4*
Permission is hereby granted to dispose of the human rema' s described above as indicated.
`': Date Issued:3-1 7-I(o Registrar of Vital Statistics ra,_: W Q_0_L3
`' . (sig Lure)
District Number S Place \-t -.„T ,i1
•
I certify that the remains of the decedent identified abdv were disposed of in accordance with this permit on:
W Date of Disposition 3)2)in, Place of Disposition Ulu, C a(rw,
2 (address)
LGJ
0
CL (section) (lot num r) (grave number)
G Name of Sexton or Person-in Charge of Premises
• ��„fp�r- �"+`��`
Z /,f .,��j,,l (please print) I
1 Signature �L - Title 1.00134.
- (over)
DOH-1555 (9/98)