Monthung, Harland NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir t . `A ----mil Middle M Last Sex
111
Date of Deatfy Age If Veteran of U.S. Armed Forces,
.), 1 / A o, ( c3S7 War or Dates ' --,-) 1... ..)
l- Place of Death / Hospital. Institution or
Z City, Town o llage C� r:fk41% Street Address
aManner of De* Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined C Pending
LU Circumstances Investigation
W Medical Certifier Naw Title
C1 61A a r k t„j . P..f V y. M. D.
Address / }
Death Certificate Filed /' District Number Register Number
City, Town or Village Cc C`1--.1s-- Li-C.1
Date Cemetery or Crematory
—
Burial 1 /`3 i /),Ai t ;'Ae V ,'e w �t,„ 1-6 r;�,�
Address`\` ,
LJCremation c_3{Lkee^5 b- r f\i, t
Date J / Place Removed
Z —Removal and/or Held
pand/or Address
O Hold
O Date Point of
53 n Transportation Shipment
a. by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to ,--- Registration Number
Name of Funeral Home Ce.,4sA-0•e -7-7 ,er4- ( (-}.".) 3,,c o0 ,-t`rZ
Address n
7 Sker ,..a l4ve> >r;q l AL 1 r
� ic a -)
Name of Funeral Firm Making Disposition or to Whom
i''' Remains are Shipped, If Other than Above
Address
14
Permission is hereby granted to dispose of the human r= • = • :scribed ov= •s ' •icated.
Date Issued I/%i /a°`( Registrar of Vital Statistics Ago - 4 •
IMP'•a ire)
v
i District Number c- 1 Place C r' . -/ 6 `"' r dr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition FKjj ) /2o{,1 Place of Disposition gn.41). Crrii►•4fei,Lk-
2 (address)
cu
0
cc (section) , i (lot numb (grave number)
° Name of Sexton or Person in Charge f Premises iI\Ttur- S o".461-
r (please print)
1 Signature Title rn 1visott-
1555 (10/89) p. 1 of 2 VS-61