Shelton, Jerry NEW YORK STATE DEPARTMENT OF HEALTHZo
Vital Records Section Burial - Transit Permit
`: Name First Zaddle t ep �SC
Date of Death7-4°41r(LA
. Age If Veteran of U.S.Ann Forces,
/U l l 7 i / 7 7 Dates Alt4,,yYd"
•f Death C
_ Hospital, titutian or1 wn or Village L(�'�.S IJflL c ddress L ;,),_( Fig ve_S
• T anner of Deathatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Tale
ffi /Agog
„,„
Address <•_
7 c-, ,--;-,
a Certificate Fit District Nu r Regis r er
vil City, , own or Village�L ,�� ,/ ( �
ISA-01,7J T5---• Ald 2-0- C"/;x3 Folks._
■Burial Date Cemetery o Cremato p1///:;1-
i
TTE mm 1d�1�' lI -�❑ n bment Address1Ki remationiiiii
j U�� dDLPL .c)SlL...I1DatePlace Removed
f}❑Removal and/or Held
and/or Address Illi
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Zi Carrier
Date Cemetery Address
I❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
f ` Name of Funeral Home c„ynard -faker Fu,nero..1 ;y 0 130
Address I La-CO-yst..AAC 5-k. , Q e S .cy , tv e> "kr V_ 12 ci 0 LA
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
ILI
Permission is hereby granted to dispose of the human remains describ a v as- di
== Date Issued /108/2 i/ Registrar of Vital Statistics
(signature)
j:;' District Number 5-4 0/ Place 6/ , A-A , >
`- I certify that the remains of the decedent ideitWiied above were disposed of in accordance with this permit on:
Uit Date of Disposition to i i'i I i\ Place of Disposition 1 '0 iL tti.I Cry{(ra,,�
. 2 (address)
w
(section) sk(lot number) c- (grave number)
40
Name of Sexton or Per.in in Charge Premises h(r, ,- JoAt'
/ P (p a
se print)
S44 ignature _ l _ Ttle (Pie:Mf'rco
(over)
DOH-1555 (02/2004)