Clothier, William 1
NEW YORK STATE DEPARTMENT OF HEALTH i d
Vital Records Section Burial - Trans Permit
Name First Middle-- Last Sex
0,7
Date of Death / Age If Veteran of U.S. Armed Forces,
l i5/a''1 War or Dates
1-. - of Death Hospital, Institution or
own or Village G r -}�, -3 r%1 Street Address $ra-4-_ )4 -
m f anner of Death 11ILI Natural Caae � ccidtnt Homicide �Suicide Uaeterminq Pending
y Circumstances Investigation
W Medical Certifier Name_ Title
Q _)eA i•l-i L{r:41 M
Address
ail a(r,,,, . VT c_SAr,4` &Yr 1.Z166-,
D Certificate Filed - Dist ict Number U Register Number
own or Village - ra-{ r.,, S °(
❑Burial Date Cemetery or Cremato
['Entombment / a-- a/ r\���/ �.� C Icar ,_..
Address/'�
lJCremation L2C,..�c..C- S, r ) /LVe,., c,, _
Date Place Removed
Removal and/or Held
..,, and/or Address
-a. Hold
Date Point of
ti Q Transportation Shipment
G'>r by Common Destination
Carrier
j Et Disinterment
Date Cemetery Address 1
Q Reinterment Date Cemetery Address
Permit Issued to ft
"" Registration Number
Name of Funeral Ho ,. ��_.As . rr ke_eAl (-19--c 1,=--- 0p4-1`t-g
Address -----7 X er,v1A-e, A-v6 i .)/`:-.0:7 --Arr id IS a-j___ _
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I
II': Permission is hereby granted to dispose of the human remains ' e bove ' icated.
Date Issued ‘ ,.®// (- Registrar of Vital Statisticsr.
(signature)
District Number y 5-a( Place _ �� y
I certify that the remains of the decedent identified above were dilposedrn7-
accordance with this permit on:
2
gDate of Disposition if120 (16 Place of Disposition ZIL-- 13 ,,,
W (address)
U)
}C (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises t
z (pl ase pnj tril
LU Signature J. Title O .m 114
(over)
DOH-1555 (02/2004)