Champagne, William d .
NEW YORK STATE DEPARTMENT OF HEALTH � c
Vital Records Section Burial - Transit Permit
i
Name First Middle Last Sex L
Date of Death Age — Jf Veteran d1:td.� Arjed Forces,
$/ 3/ a o t�i 5 `t War or Dates 1 9 74- — 7 '
I Place • 1-ath Hosppiiiil, Institettiolc'or
CI i.Town o Village Cif, Street Address
A M.- ;. 'teeth Natural Cause D Accident Homicide D Suicide 0 Undetermined —Pending
W Circumstances — Investigation
ill Medical Certifier Nam Title
CI 1;GPI Ael- 6, Kr�bi -.k A l N.
Address
l( HOLIL -. me-) Atisuk,,1 i 0 `1 1a1.53C
Death_......-,--
ate Filed District Number Register Number
City • ., Village 29P,icC ss
Date Cemetery or Crematory
—Burial 0/540I e ,. 1I (7)ev7e �.k "-4e -
Address Q .
. i.Cremation (eLk:CC A1f Pe-w YDr-it vvv
ZDate (� 7 Place Removed
O U Removal �1 and/or Held
I^- and/or Address
Hold
O Date Point of
NTransportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Horn _w�Sivt-af� J ,1 A. Tt'°"42i 00
Address cA r Ave
l NA - ^
Name of Funeral Firm Making Disposition or to Whom)
Remains are Shipped, If Other than Above
Address
i
Permission is hereby
ranted to dispose of the human r ains scribed ov: •s ' •icated,
Date Issued g/t o Registrar of Vital Statistics 0(4 /
Cra re) y�
District Number 1't•5-S3 Place �� :kk , Ajc�s / 'or`
l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition Y-tr"1' Place of Disposition 'Iv �t'-+ `-tom^e to I Iv.,
2 (address)
u.!
0
CC (section) (I t number) (grave number)
0 Name of Sexton or Person in Charge of Premises gli,s_t_,
Y-- P�•-tbf
4-1
Z (please print) // _
W Signature Title Cd r rkCL
•
DOH-1555 (10/89) p. 1 of 2 VS-61