Matthews, William NEW YORK STATE DEPARTMENT OF HEALTH „ LI
Vital Records Section Burial - Transit Perm
•
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.: Name First ] 1 Middle st +- Sex
/11
%' Date of Death Age If Veteran of U.S. Armed Forces,
ar
/3/Aati 63 War or Dates
Place of Death Hospital, Institution or
ie' i Town or Village (5/c..^s 1"-t)s- Street Address
,„ anner of Death®Natural Cause Ei Accident 0 Homicide El Suicide �Undetermined �Pending
Circumstances Investigation
Medical Certifier Name, Title
Address
„fri_ k--- ox,
A,! : h Certificate Filed U�
pc,,,,(A,,, 6L, -Tms, N. i txt,o I
IDistrict umber Register Number
` ` ,Town or Village CLegs -ftl..\1c 5 of 433 ,
Date Cemetery or Cremat
❑ Burial iP/ ,I l d4t1 ;nG.v1�..... 6,M�4.,
Address i)
Cremation �.�C..A . .�; A.)�.� `ior�
Date i Place Removed
O Removal and/or Held
and/or Address
Hold
C Date Point of
N 0 Transportation • Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ini Permit Issued to Registration Number
miiName of Funeral Home a---C..4.‘5,v,'re— 1.-LA e.r..( l -•^'^‘ , = . O a zf`f,
: �. Address _.
`° Name of Funeral Firm eking Disposition or to Whor i
°°" Remains are Shipped, If Other than Above
:v- Address
Iii Permission is herebygranted to dispose of the human remains described above s in at d.
Date Issued I e9 /
t./ a'i1 Registrar of Vital Statistics 4#‘47I ga
(signature)
OF District Number J - 0/ PlaceC F ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition jC— --)ot( Place of Disposition t';r'1,,,,,,„, C P'emtec ri Lr:vi
2 (address)
i1J
cc • sec ' ) (lot,number) (grave number)
Name of Sexton or Person in Char e of Premises I i n-t n�-k IJf v;Ae(te. •
2 (please print)Y
.40 Signature 4 Title C -e v►cs-t-cw-7 14 -
(over)
DOH-1555 (9/98)