Corliss, Richard #.ii3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
og Name First Middle Last Se
IASSA
iin Date of Death 1 Age 1 If Veteran of U.S. Armed Forc
Z I �, �o j' i War or Dates Jer.
0-
;4 .- of Death I Ho - stitution or
own or Village VI L Lr�S F �j Street Addres )S O� �5`
• 1 4,1 ner of Death Natural Cause 0Accident Homicide Suicide n Undetermined ri Pending
Circumstances L__:Investigation
A
f, Medical Certifier Name if Title
o / t }il
( G low- r d< i K,l c�
Address // he-_,-,
it e 4' ' 1 Gam_ kee
g,,,, ath Certificate Filed (y i District Number Regis er Number
Cit own or Village k .� /1p?.-1 - l s
Date / Cemetery o' - remato
❑Burial / / 1"-- : :i.-,) ef 1/-41--)
Address /�
IANKremation V C-'� Ca. Li32✓,.�� z 17
i Date Place Removed
fl ❑Removal i and/or Held
-• and/or Address
0Hold
0 Date I Point of
ikE Transportation, ( Shipment •
3 by Common Destination
Carrier
. : Disinterment Date ! Cemetery Address
s
1-1 Reinterment Date Cemetery Address
=' Permit Issued to - ;� I Registration Number
iiiiii
i
:i;is.,, Name of Funeral Home _ , L�f? �z X '_ h-,;.,, -111;: }_ :s,,- 1 On/30
- Address //- " -,
/l t,�l'F o L1 C'r t _ i3&iceJS. it U/2..�:i / I 1 cF-C-' `/
;; Name of Funeral Fj' Making Disposition or to Whom I
Remains are Shipped. If Other than Above `
Address
IX
10
PS
<> Permission is here y granted to dispose of the human remains des ri ed bo/y�etias i i ed.
oi. Date Issued 0eVeY6 Registrar of Vital Statistics /��, L�
(signature)
District Number 6— 0/ Place (2/./I i.". AA./ /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
5 Date of Disposition-a- -•I Place of Disposition ,nc.�f w crvvi c1(6,
a (address)
Lid
VI
(section) (lot number) (grave number)
O
Te
Name of Sexton or Person-in Charge of Premises f M e.,x' J ,,Rs ,
Z (please print)
LU Signature /- /r Title C.,ct,r i}GC
(over)
DOH-1555 (9/98)