Eddy, Garrie •
•
NEW YORK STATE DEPARTMENT OF HEALTH c
31n
Vital Records Section s Burial.- Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of'U.S. Ar d Forces,
5737ao/6, 7 War or,Dates (966-- 7c
- Pla e of Death __, Hospital, Institution or
pity own or Village Le-__+«0. ---.- Street Address Z ,
a Manner of Death®Natural Cause Accident Homicide Suicide Undetermined Pending
IW Circumstances Investigation
W Medical Certifier Name Title
as r
Address / •
Q / i
I CAte f kj akeUSD�r 1 I t'aWo7
D Certificate Filed District Number Register Number
=' own or Village Le.,., 'f' — _ 5-6-1 ..2 3 7
<< ❑Burial Date Cemetery or Crematory • '
Entombment S/ `7V.2 o/ G I
i�✓'d-.,.., CcM 4-4'�
Address
iiiiii Cremation .,&LGA,,,..4,..r to `i •
Date .0 - Place Removed
Z❑Removal and/or Held
and/or Address
• '` Hold
O.
O Date Point of
05❑Transportation . Shipment
by Common Destination
gi Carrier
El Disinterment Date Cemetery Address
•
Q Reinterment Date Cemetery Address
•
': Permit Issued to _ Registration Number
• Name of Funeral Hom .�-✓t.5 m,72 fi Ae ru- ( q-, � oa `-•�`eg
. iiiig Address -
gi,i
iigiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
C
til
3 Permission is hereby granted to dispose of the human remains descri d above s in ' ed.
gi 7y Date Issued 5 /a 0/6 Registrar of Vital Statistics "L
(signature)
District Number Sao ( Place 6 z,,, ��, (i - Nc,_, Yor(
io
"' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition S I SliC Place of Disposition iil,( ^,,,
1 1 (address)
ta
CC (section) n(lot number) (grave number)
Name of Sexton or Person in Charge of Premises A ref ,\14
-z► (p ase print)
gA Signature a Title f�f �.
(over)
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DOH-1555 (02/2004) •