Coulard, Francis E � 11
NEVI!YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . Burial m Transit Perm
a Name First Middle Last I Sex
�rrxnC S tTn �V 1� a
tri Date of Death I Age I If Veteran of U.S. Armed Forces.
1:)21\$ , 2_01 to i "89 i War or Dates I q5 i - 1 G 55
Place or ath 1 Hospital, institution or
City, r Village C371/4_82e \oo rj 1 Street Address "The_ S -p,rr'-c3 Y )
Manner or Death Natural Cause 0 Accident El Homicide Q Suicide El Undetermined Q Pending
14 Circumstances Investigation
IQ Medical Certifier Name Title
BC{\t'lCv .O VI C n M 't
Address
2Lt CQb b1-0_S n e -t);( v Qv c,sYoo-,-,1 Alt r�$vc-1
Death ertisicate Filed I District Numbers - I Register Number
Gity. oUv r Village Q erISbk- f( LO S 1 i- 21-1
_ I Date I Cemetery or Crematory
_Burial 1 6o-L ' IG} I ..0 1 o i •--'i► e Ui ev3 er( enic ksr
I Address
:54 Cremation) \)ePv S\c se 1 Z Q L
I Date / }; Place Hemoved
X—Removal I and/or Held
n and/or I Address
Hold I
Date Point of
—cil Transportation.I . Shipment
a by Common fi Destination
:.::: Carrier
Disinterment Date Cemetery; Address
I
[�Renterment Date I Cemetery Address
i
=' Permit issued to 1 Registration Number
_-- Name of Funeral Home_ ',:i- _ -"�`:r�•Y_ I ;y -- 1 Oil 30
Address i {�
f i �P)'�?�=f t.'f l u mil; t/om}E.)6/.:. .��f�i C.)iL-4- /l�' -/, / c Li -
Name of Funeral Firiri Making Disposition or to Whom :i i I -
Remains are Shipped. If Other than Above `'
: Address -
1AO Permission is hereby granted to dispose of the human r "ns desc -. _... • indicated.
Mt
Date issued D-I q- bicp Registrar of Vital Statistics � ..1 J-Q . 4(
el (s tiara)
: District Number CLa5 Place 40(J.N.SM
c tig-n
I certify that the remains of the decedent identified above we disposed of in accordan ith this permit on:
Date of Disposition 2/ZZ1fb Place of Disposition 40/.,a ,(rrm►ctOt' -
2 - (address)
tri
(section) 4/(lot number (grave number)
0 Name of Sexton or Person-in Charge of/ emises /� f,lve4( sM
(please print)
.4 Signature J NI;it: Title 11l6I Il
- (over)
DOH-1555 (9/98)