Fogarty, Patrick !, YORK STATE DEPARTMENT OF HEALTH t
-ecords Section Burial - Transit Permit
rk, ,14
ame First Middle Last Sex
N.
/c.i _ -3-✓4// 3 Fo 1 /Y.&l
:-. Date of Death Age If Veteran of U.S. Armed F• ,
fin* / S. 9 W. or Dates A kg-
''.
of Death 4 Hospi r nstitutionpr
own or Village C)t.i5'.Js, f,g- ,_.c i eet Address ( 1. ,i 5 /iu s
k Manner of DeathNatural Cause 0 Accident El Homicide 0 Suicide Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
?^ Address `
mi • :mot 6 1 Cam' Ub1 itiS(3 L1z IR
'•-.t Certificate Filed / 4 District Num ister,i� -r
t �ity, n or Village C t 6:,,r3 f--fi- L_S ‘
Date Cemetery Cremat t r
Q Burial // /2-'2—I / r,..se' ld/61.-3
,, Addressa,l
remation g 7L 6 . 12� Q"0)—.4, s Q7 . /07 p soi
Date Place Removed
u❑Removal and/or Held
and/or Address
Hold
d Date I Point of
Ti u Transportation 1 Shipment
44
,,-;4 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Ha ynard b. &Aker Fwiercz/ /lome_ Q1 f 30
Address /INI Lctrcuye, to 3 '• , bu nS x c. ,1AJuo L/v/k- 1a8Uy
a.,; Name of Funeral Firm Making Disposition or to Whom
s• Remains are Shipped, If Other than Above
Address
z
k. Permission is ere y granted to dispose of the human rem-ens d- 'bed abo - as indi : ed.
101
Date Issued l ' 7 7JJ(p Registrar of Vital Statistics /1 �r�
3,
(signatu -)
# District Number PlaceLx-�%'
f L� 1
I certify that the remains of the decedent identified above were disposed of in.accordan a with this permit on:
• Date of Disposition ►(i r s1 ly Place of Disposition 2
i 1► ( �f=v.►� 4r
(address)
•y (section) ,(Iot number) ((. (grave number)
i0 Name of Sexton or Person in Charge of Premises / ns(cyli.i it'PIN
(please print)
Signature C� Title CEftiflGg-
(over)
DOH-1555 (9/98)