Fournier, Terry NEW YORK STATE DEPARTMENT OF HEALTH' W # j 7 t
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Vital Records Section Burial - Transit ermit
Iii Name First Middle Last I Sex
Date of Death j Age I If Veteran of U.S. Armed Forces,
03-1 X -2-c i 1.D Sq War or Dates N , Pr
ce of Death ! Hospital, Institution or
+► , Town or Village c3 k e N -- ,1l S' ! Street Address lb WAN) ,j\-ree4- 6t;,2
m Manner of Death 5f Natural Cause E Accident El Homicide 0 Suicide n Undeterfnined r Pending
W� Circumstances Investigation
• Medical Certifier Name Title
Acre) A. - villa I`'t17
Address I zQa 1
/U 2. P&(1_ Si-f,e_-k- Pro R'vi\1• on , (7)ens- �t Ils, Al Y
Death Certificate Filed 1 . Distr1ct Nu ber Register Number
own or Tillage Glens- '1 ? + 1°j3
j Date i Cemetery or Crematory
::: LJBurial .i 03 ) )5 J ao1 et�� e \l ► �; C�rern� ��
.. I Address fi
A Cremation 1 P n,a y 7 N \ ' �-
Date • Place�emoved
0 r—iRemoval ` and;or '-!eid
9 and/or Address
— Hold
( ! Date I 'min:of
N1 Transportation I —_ I Shipment
25 by Common Destination
Carrier
Date I Cemetery Address
—I Disinterment
Reinterment Date I Cemetery Address
. Permit Issued to t - ' Registration Number
�
-< Name of Funeral Home 6Ct er /— rcc/ 1/ome_
CGf ) 3s✓.
Address
>< %/ l_Cci ruy CitC Jt. , t.t_t nsb' i-r , A ts1 tlar)= l eo
Ig Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
Address _
IM
>` Permission is hereby granted to dispose of the human re ains scribed ove as i slica ed.
Date Issued -)/t j /47 Registrar of Vital Statistics 5i/-r
:i»
(sign tore)
II'<'; District Number •5-6d( Place ,, C.
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
' Date of Disposition 3//I./IL Place of Disposition got,l r Crri►Crof j.
2 (address)
= (section) ,(lot numbe (grave number)
fj
Name of Sexton or Person in Charge of Premises rrJ .- taot(t-
Z
? . (please print)
tfil Signature Title rfaattgig
(over)
DOH-1555 (9/98)