Day, Pam NEW YORK STATE DEPARTMENT OF HEALTH 5
Vital Records Section Burial m Transit Permit
Name First h ie La ( SeX
tWi /7& itc I 1 Y179LL '
Date of Death' f Age I If Veteran of U.S.Armed F ces
/3 // e .�2.- 1 War or Dates .�`—
Placa e 0 ath ' .• :- • titution or
City,
111
. Town •r Village A►2 c ' Street Address a 63 kh Pi n ,7-Cl/ �s - -61r!
Manner of Death❑Natural Cause 0 Accident Q Homicide ❑Suicide 1-1 Undetermined PC Pending
LEI Circumstances t Investigation
ill Medical Certifier Name ) Title
I / / IC// -ire__ i4)/LICag A ,);
.:„:„:,
,_:,:, Address M ,(/ /
�a /l C/1 d3 a-� �', Q`LCS m.J Lele t' A) /2-6 2 j
;: Death ificate Filed /i I District Number Register plumb r
-. City,(Town r Village /[ 0 2 t, I s C��i v2 y
❑Burial Date Cemetery Cremat+
s'))� I� �JE,rly
II
LEntombment Address /-"‘,
;Cremation �( u enc&-� Q J 6,e-A s_ uy- Pf/
-"`` Date ( Place Removed 7/
k C Removal ( and/or Held
and/or�a i Address
Hold
0 Date Point of
C Transportation Shipment
by Common Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment Date 1 Cemetery Address
Permit Issued to ` Registration Number
-!- Name of Funeral Home &•Ci-1EX C"�:,\e_,Zx\ hp cc C'�,1 1 ?0
Address
11 Le Cal t_ -k- Lt C_N( .\- L ! K\ 1Z c
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
l
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8,1/51/6, Registrar of Vital Statistics _4 /fjJ ez '�—�
(signature)
District Number q 5 Place 7b e✓-'t o e- A0#ce et
i certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILL Date of Disposition lg/l`f/l Place of Disposition ,u(iL 1 n4'}or...i
(address)
ia
01
la (section) (Jot number) (grave number)
O.
Name of Sexton or Person in Ch ge of Premises t�f cL._ -3c4A4"
(please
Signature4 Title
(over)
•
DOH-t 555 (02/2004)