The URL can be used to link to this page

Morehouse, Leslie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First j. Middle Last S ii Date of Death Age / G� If Veteran of U.S. Armed Forces, -0-"bn v /4/ OWLi / War or Dates 14 P �e of Dea / Hospital, Institutio o ,�� ' Cit Town o illage (S/��''`�tc-/ drf Street Address j� f, / p�/ 4 25 ) Ili Manner of Death atural Cause Accident 0 Homicide Suicide Undetermined P nding i Circumstances Investigation fa ja Medical Certifier gt. N e . Title Q 1 /7 fly/ 7 0T/v < ,/' Address 'kWh ). (3. csY,' Xl? ? iliii Certificate Filed y� — District Number / R4/745--le,..,7,2 � ister Number Ci , Town or Village L9�1�lf t,- �i��, g 7e' Biii Burial Data"1 1f A© j/ C or Crema /'� > >❑E ombment Address 6 �� 12G t �` /� 4� Cremation (/`4( ,J/) - u�� ' Z�, ._ /'�" //�� Date Place Removed Removal el and/or .' and/or Address / Held I: Hold 0 Date Point of It0 Transportation Shipment • Et by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address 10 Permit Issued to �� ..-" Registration Number Name of Funeral Home .17,4'7 1 C G%—/?9' <: Addres Nam of uneral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above '„ Address al LL Permission is her by anted to dispose of the human remains described above as indicated. Date Issued L l r l Registrar of Vital Statistics 1ry ck.,.,Y.,��„) / C� �s�gnat District Number ga Place 61, / 6pliz.,r l�J I certify that the remains of the decedent ide fied ab ve were disposed of in accordance with this permit on: k Ill Date of Disposition ' ilk o g o 7 j Place of Disposition PAL 0 it.,, C renry.Cf0 r,,,,_ (address) tii C (section) (lot num r) (grave number) et � CI Name of Sexton or P, rson in Char a of Premises i 1,Ask i0'Nr ' 9v..f(+ Z 71,L 1 (please print) Signature Title C1�ii4�11-r0C (over) DOH-1555 (02/2004)