Philo, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' . elp Burial - Transit Permit
1p Named,rst he,,x,7
j / �Medle ,4 Layb
ate of Death �/ •- If Veteran of U.S. Arm d F ces, /
Jl -- / ' `/ 4 War or Dates Cf 5--l9/0L,
Place r IN-ath / Hospital, Institute or /
City or Villag- IV d •, g- L Street Address/ 4 /I � �,�1j75,j)& INAI/1l
1.14
0 Man - . Deat IR Natural Cause El Accident D Homicide E Suicide ri Undetermined ri Pending
Circumstances Investigation
ILI Medical C lifier Na a Title ri
.i, 7 , ,tbss fi-d- (c .ter cC AL? /
Deat ificate Filed District Number Registe Number
City Town r Village ( J� 5-7 _1
❑Burial D 4// "riFtery
or r atory /I ( r oia /
❑Entombment "`
A
) tremation ( I (-c.,t_p_n5 .J 7)
Date ' Place Removed
❑Removal and/or Held
and/or Address
t Hold
CA
O Date Point of
Transportation Shipment
Gs by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to n Registration r
Name of Funeral Home /� ,E,,/jy�,1 ,„!/ 2fejfito oi,p
Address
Name of Funeral Firm Making Disposition or tb Whom
Remains are Shipped, If Other than Above
Address
III
CL
Permission is h reby ranted to dispose of the human >• ains described above indicated.
lal Date Issue 1 Registrar of Vital States . ,
(signature)
District Numbe �j 3 Place
I certify that the remains of the decedent identified ove were disposed of in accordance with this permit on:
111 p 4Lo _.1 L -*.Date of Disposition q-11-0 Place of Dis ositionnt..-
2 (address)
La
to
a (section) (1 t number) (grave number)
Ct Name of Sexton or Pers in Charge of remises I 1'11 r
w
lease print)
iii Signature �
g Title
Co%h►tb o!L
(over)
DOH-1555 (02/2004)