Frye, Dean f • gig
NEW YORK STATE DEPARTMENT OF HEALTH L' '.,.?r-!:„r3:+- . / •
Vital Re
cords Section Burial -Transit Permit
iN Name First Middle Last Sex
` " be (L_I� - jf iCt.
Date of Death Age,,: . If Veteran of U S.Armed Forces,
. : . . ,, w 1 71
)(:p 4. . . ,War or Dates ,L)(A
4 Place of Death Hospital, Institution or
or Villa a r.i r1 , - .� !4 Street Address (.t t III
• Manner of Death®Natural Cause Accident -0 Homicide Suicide Undetermined ending
Circumstances Investigation
lui Medical Certiifier-f....‘ Name 1 Title
r • . l'rmA 4\ifti � Sou, a- (ier NA .. -
€ k Address
' to 1 eartAi
Rd aue,e,nsbonj
Death Certificate Filed � - N- District mber 4.4my :. Register Number
H�. 55
:.:. . . . ,.- ,Date :. . etery or Cremato ..
❑ dre
Burial . ac ` 1 u _)n2.. r 1 e to rilato
Ad f.
Cremation
Date Place R moved . F . •
O a Removal and/or Held
•,!. and/or Address
g Hold
Q Date Point of
N0 Transportation Shipment
5 by Common . Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
.1 Permit Issued to Registration Number
€l Name of Funeral Homef 3r- u .t -2.. rJ --o 'y L1 I r C. otco ! I
Address
II - ( 24 u h - L LkiL L.u7_la.-19LQ I ? g 14(0
IP Name of Funeral Firm Making Disposition or to Whom
`•Remains are Shipped, If Other than Above
til Address
117
a Permission is h reby granted to dispose of the human r sins d cribed bov s i 'cated.
ig Date Issued 1 '1/I (.• Registrar of Vital Statistics 1 et, 1
- signat e)
District Number 455 3 Place ( Cr fI 1 / Al i - -
•::.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
6 Date of Disposition 3/Z/IL Place of Disposition Re V,t j Cjrmwito. '
(address)
in
CA
CC (section) 4 (lot, umber) (grave number)
D Name of Sexton or Person in Char a of Premises thr, /ts, Siii
z (please print)
li Signature 4 l Title of-sinK
DOH-1555 (10/89) p. 1 of 2 _ . '_; r; {e:;'00 6Y E`'iVS-81