Loading...
Grant, Victor NEW YORK STATE DEPARTMENT OF HEALTH' # 7z g Vital Records Section Burial - Transit Permit Name First Middle Last Sex V r^ 'rci n t., Mel le, Date o ath Age If Veteran of U.S. Armed Forces, 10 f I 2Oi Cvg 1 War or Dates 1 col S t-- Place of eath -- Hospital, Institution or City Tow or Village (_j,Lz �� Street Address 19 3 ~&ofj e Id Nag W Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation iii Medical Certifier e � Title Gt DY . U..1ii hit j I l O/1 M 6 Address G)tr1S a1 I5 .W Death Certificate File / District Number Register Number City, o w or Village LU, -ryj 560, 4p 1 ❑Burial Date _emetery or Crematory/� ['EntombmentI© 3 20/60 1 t }le A f.u� ( —!Y'I/ ry Addre ;;;;;;;;'Cremation (vim S buyj Date ( Place Removed Removal and/or Held 1-1 and/or Address E Hold to Date Point of to❑Transportation Shipment C by Common Destination Carrier Disinterment Date Cemetery Address N Elil Reinterment Date Cemetery Address Permit Issued to �� Registration Number Name of Funeral Home , yey- ��//'1tral ' n€t /176,, 00 // Address 0 .1- Church St-- LaJa La7.14--Tu AApag1/4. il Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address IX Ill P` Permission is hereby granted to dispose of the human re ains des ib d above as indicated. {/ Ei Date Issued J -Lf-1(p Registrar of Vital Statistics . /C.e ` (signatur) District Number s(J'3(0 Place i .aJ2.( LIA VIL.4C-1..._ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILI Date of Disposition /o/b/It Place of Disposition nOtth, C r i cvtc'0... 2 (address) lit Ca CC (section) I/ (lot number) (grave number) • Name of Sexton or Person in Charge of Premises t{0S r Jt+rat�'- ( lease print) • Signature a Title f rfkif}(?1i2. (over) DOH-1555 (02/2004)