Mattoon, Arthur NEW YORK STATE DEPARTMENT OF HEALTH b
Vital Records Section N. Burial - Transit Permit
lill e First Middle Last Sex
fii > y k _
Date of Death Age If Veteran of U.S. Armed Forces,
/ —(Q - /j 7 a War or Dates M 5`1- /9 c,if
.14 Place of Death y �, Hospital, Institution or )
ity, Town or Village 't°QwLo l�]& id Street Address ... e .LL H2 T
%/ O
0 ner of Death®Natural Cause ElAccident ElHomicide ElSuicide ❑Undetermined Pending
Circumstances Investigation
ut Medical Certifier Name 1 • Title
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Death Certificate Filed l District Number Register Number
i;g(C-4 Town or Village `2j —1-tal..13 0
gii Burial Date C -neterytory
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Crem
❑Entombment l a 1 1 9 1 + -fr` i .tryV Y
Addres
;' ,Cremation p,yw b uL ii-Li IVTIDate I " Plce Removed
g❑Removal and/or Held
and/or Address
to
Hold
O Date Point of
Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
in Permit Issued to Registration Number
Name of Funeral Home j/�p , ,j 4k_L l �,p Yyk-Q_ j y� 004 + +
Address � !
,4 cc\uu,01, �t- Po �6 Soo JL1:, i ,�� 0 I w1 t�$l(
Name of Funeral Firm Making Disposition or to Whom j J
14 Remains are Shipped, If Other than Above
• Address
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tI
'` Permission is here y granted to dispose of the human remains described a ve n icated.
Date Issued 1a s8 )‘ Registrar of Vital Statistics L�i
D
(signature)
giii District Number jer Place ( _,„,,k_., R J
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,...,,,„„,::::, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U.!• Date of Disposition pK, 1 NI Place of Disposition gtAtUit�J C..rtnref 0ftio .
(address)
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CO
CC (section) A -- (lot num ) (grave number)
a
ei Name of Sexton or Person in Charg f Premises 1t5\ 11 Q R*+f
(please print)
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Signature Title ce€ -1d(2--
(over)
DOH-1555 (02/2004)