Glacy, Ada ,# -77
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ^: Burial - Transit Permit
Name Fit-144_, 1 Mi le ? ast Se
Date of Death A If Veteran of U.S. Arm. i Forces,
it,a5/`( 80 War or Dates
1 Place of Death Hospital, Institution or -em
`n&City, Town or Village 'LQk'{1, Street Address/el a, '� .
-Y -i s 4J
0 Manner of Death T Natural Cause El Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
ILCircumstances Investigation
W Medical Certifier Name Title
A-p A VI' rC.,
_a; �Addre e•- l� �'l 0, 1
Death Certificate Filed Distri t tuber Re ister umber
9
City, Town or Village ` f'1C9kP.��.1.C� �{ po1—
urial Date /b��12/f ,,, I Cem�erL je�Q
❑Entombment Address (f7 �/ j�
Cremation &y4 'a. C:�C-
Date Place Removed
9❑Removal and/or Held
and/or Address�
fa
0 Date Point of
ai❑Transportation Shipment
0 by Common Destination
Carrier
Li Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to `J Registration Nuub er
Name of Funeral Home'O J 0/078
Address / 2 277 la- _12 }s - L7
Name of Funeral Firm Making Disposition or to Whom
1.4 Remains are Shipped, If Other than Above
„ Address
.I
t1 Permission is hereby granted to dispose of the human remains des ibe above as indicated.
Date Issued /(� /20/�o Registrar of Vital StatisticsOA/
n -/ (signature)
District Number % Z Place 3 ) /?L1'f)o id, fed. if),f o t L1i Ay / 2 1
1-
..: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ii l Date of Disposition !D/Z7//1, Place of Disposition ln.t 0ii,� 6*m 00 r it)A-,
2 (address)
Ili
I0
CC (section) / (lot number) (grave number)"�
Name of Sexton or Person in Charge of Premises CA ,r So"^t "
2 (please print)
I Signature Title ( r�I�V�2
(over)
DOH-1555 (02/2004)