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Hartman, Floyd t NEW YORK STATE DEPARTMENT OF HEALTH s53. Vital Records Section ' Burial v Transit Permit Name First Middle Last I Sex i 0,1 d tali-Vrn/a n i t\ `i Date of Death Age 1 If Veteran of U.S.Armed orces, 081©ct 12-61 Q. I .86 ( War or Dates 1 GS 14. Place of Death Hospital, Institution or own or Village �� t‘,� Street Address Gu-Y>S FrAAS . oS e; +C%. t _ El Manner of Deati t Natural Cause Accident 1-1 Homicide0 Suicide Undetermined Pending L1 l�/" Circumstances Investigation Lu Medical Certifier Name Title William Cleaver HD Address 100 Pax k St-1 G len s Y' S NL/ )2go 1 �.Jeath Certificate Filed I District Number �j Regist r N Town or Village G- eoS act it S F C1 � Date Cemetery or Crematory El Burial ( I 15 i .Zb‘ i>❑Entombmenti v ` a `�� Address u':Cremation ak v:L\(c �( '�.pl� (k �P�y,�S� y I �Z ►j Q 9Date Place Removed ZC Removal and/or Held and/or Address t Hold En O Date Point of Elks 0 Transportation Shipment • by Common Destination Carrier '❑Disinterment Date Cemetery Address Reinterment Date I Cemetery Address Permit Issued to Registration Number Name of Funeral Home . `Zc X Z;,,\t-c1.\ -D i11"(-1- C--_)i t C Address Lc c eL Si4- CL L.- .. L 1 1 KY +-z e�1 Name of Funeral Firm Making Disposition or to Whom k Remains are Shipped, If Other than Above • Address la Permission is hereby granted to dispose of the human re sins de cribed a ove as in Gated. Date Issued( �//cj/ j/6, Registrar of Vital Statistics gr�� j--� ` 6 (sign re) District Number r Place 2� 6 - '� , 1 I certify that the remains of the decedent identified above were disposed of in accor once with this permit on: 111. Date of Disposition Q f(1 i(6 Place of Disposition g rt.,- 2 (address) ta EL (section) 4 (lot number) (grave number) tz Name of Sexton or Person in Charge of Premises / ('tl Wj . ( tease pnn Signature 4 Title (it f4 $lJt- (over) DOH-1555 (D212004)