Moyer, Charles NEW YORK STATE DEPARTMENT OF HEALTH t #
Vital Records Section Burial - Transit Permit
Wil Name Firstt Middle Last Sex
Ch..s n1. ?_9 tJ a 1voy .t I
Date of Death Age If Veteran of U.S. Armed Forces,
Nov. 17, 2011 62 War or Dates
) ; Place of Death Hospital, Institution or
2 City, Town or Vill&gel-y r0lr t'`''e tj 3 `AlL'" Street Address Clt?ris F'a11: (Io sp t,al
til
Manner of Death®Natural Cause Ei Accident ID Homicide El Suicide Undetermined riPending
Circumstances Investigation
III
Medical Certifier Name Title
',(f ). A. (;r;i1]_t:rr:i:i. Mr)
Address
Ng Death Certificate FiledDistrict Number Register Number
gii c,�_Ls,. n 9 .5O 0
City, Town or Village r,1 on�.; .� �11 _a 5601
Date Cemetery or Crematory
El Burial NCvo 18, 2011 Ptrip. Vt. w Cr: tnta or
Address
3Cremation 21 o a.akor { o;tti C1(y ocL b ucy, NY 1 ?r30'1
Date Place Removed
0❑Removal and/or Held
and/or Address
i Hold
0
O Date Point of
8$Q Transportation Shipment
0 by Common Destination
Carrier
iii
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiii Permit Issued to Registration Number
N1
Name of Funeral Home a ,jo 3-1_`1L<>-?` l'(If1 I ii 11()tn . 01 07o
IN Address
I C),i c.L7<l Y 't)r i t 1 y/.,1 ri'l; N; York 1 °' 3' <
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
Oil
g'` Permission is hereby granted to dispose of the human remains described abovems indicated.
I Date Issued 1 1 -1 i3--1 1 Registrar of Vital Statistics 1.)1/4)CL,-Je. liN)Jr
(signature)
: < District Number 'r 01 Place 11 Y 0 i� (r,t-r ,; IF 1.:1. ,, NIY
in
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.
6 Date of Disposition UOJ IY`ZC41 Place of Disposition at VK.a C l r(b,
2 (address)
fa
CC (section) 4, (I t numb (grave number)
Name of Sexton or Per in Charg of Premises r r iSkc r J IN,-(41"
z (please print)
LU Signature LZ Title CQ(bA-T o V,
(over)
DOH-1555 (9/98)