Mudgette, Michael 44. ISi
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last S
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Date of Death/ Age If Veteran of U.S. Armed Forces, ? /9 ,7
Lf/ �2-0/1 i 12 9 y IZS 1 ..r or Dates ye ( 13 in ,D 47b3 ,c V -uet.�,D
I.- Place of Death _, / ospital nstitution g' �--
!U ity, own or Village tt�.is �yGf�S_
Z reet Address ce.)1 �—,FEES
p Manner of Death J Natural Cause 0 Accident El Homicide 0 Suicide ri Undetermined Ei Pending
W Circumstances Investigation
ill Medical Certifier Name _ Title
_ — _ &9 (;— 0, fvo.,i iJ
Address
(3 Z P S77'. Gce',)1_ I`6z1-s /U /Lam_/
D-.th Certificate Filed District Number 1 1 Register Number
ago Town or Village c, ,.J.s F024.--5 5bC) I I t t I
•Burial Date Cemetery o Cremator
if❑Entombment 7 I�1 i —L �v"���-J
Address
Cremation a vt V , 06-��sQ Un J 2- PO Y
Date Place Removed '
fl❑Removal _i and/or Held .
and/or — _.__...
H Address
Hold — — .
0 ; Date Point of
NElTransportation _ Shipment `
C by Common Destination
Carrier ____ _ _ __ _
Date Cemetery Address
El Disinterment _ _
Date Cemetery Address
0 Reinterment I
Permit Issued to I Registration Number
Name of Funeral Home H( nca d , IScc ker o..ne r I JAC)r - — i n I l t-i(l
Address _
LOckkyQ -HC. , C u(C.n'7,bLr�/ , N e v� NA.)l" k_ 12 0`-1
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above — _
2 Address
Cr
lii- - --- -
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y/7/J 1 Registrar of Vital Statistics UD .x."k' — Jar
(s, ature)
- District Number S 601 Place 6 \\5 N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
LLi Date of Disposition it ill Place of Disposition _ I /nc�ifih! Cat
' ► (address)
U,i
U
CC (section) A
(lot nu er) (grave number)
Op Name of Sexton or Pe on in Char of Premises r.sI% Air
tAhitt
Z (please print)
ILI
Signature - Title Coe-ih ft i oe
(over)
DOH-1555 (02/2004)