Paul, Charles NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
el4R L ES qua ;Wit_
Date of Death l f✓� Age`, If Veteran of U.S. Armed Forces,
f� War or Dates
14, Place of De th Hospital, Institution or
City, Town or Village _S-1f9RI-7-6(}fel Street Address St94'/9TO6, 74
SPiZ' Z-
Manner of Death L.N.Natural Cause El Accident Q Homicide 0 Suicide rl Undetermined n Pending
1-1 Circumstances Investigation
I Medical Certifier Name , j / Title
WfLLf947 F. /-/I!L.L) /
Address
E OW CC sue- . S19RAa/9 .sU .s ;ry �d � if
.
� Death Certificate Filed District Number Registe Nu ber
i City, Town or Village JAIR0 i-66-i4
`.0 Burial Date j enetery or Crematory
: ❑Entombment `3� / ��/ J C PAA ill/m# C Er7�9-T i
Address �\
�= ( ,Cremation ) E t.A k,E 2 440, 6),,,,�c )(3uuLy . AI/ is p t y
Date Place Removed
i ri Removal and/or Held
and/or Address
-iHold
Date Point of
ElTransportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
= ' �Reinterment Date Cemetery Address
isl= Permit Issued to Registration Number
Name of Funeral Home ji9 , ,i 7/4'c._ o/WS
>a Address
l2‘ et) /9- At $ 64 r c_s At y ii&e. /
gName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I!
Permission is hereb granted to dispose of the human rem " s de "mod abcre indicate
Date Issued 302 Q / Registrar of Vital Statistics 1
(signature)
��• District Number �50/ Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3--3 11 Place of Disposition P,n e j , e `;. c,rc.w,.a.4or- ,` t
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge o remises X m®4-h.( v ne�t C
, &-,-..-it (please print)
Signature-`-- - Title C re ASS+'
(over)
1555 (02/2004)