Cloutier, Norman NEW YORK STATE DEPARTMENT OF HEALTH E .. ► # (IC LI if
Vital Records Section Burial - Transit Permit
?f>;. Name First n 1 �7-- Middle /- Last Sex
Pfil /V 0/L��nl •! use,—pii C L0 V'T 16YL_ /%9Zlf
iti Date of Death ) Acge If Veteran of U.S.Armed Fr es,
ill 2 / 4,0 > �' /�Dates J
A: -,,:,�- of Death Hos ' nstituiison or
L: 1Town or Village C I.€,.SS I ni t,S Street Address Li 0-,...., fu-u.s
.V anner of Death tjral Cause Accident Homicide Suicide Undetermined Pending
}` Circumstances Investigation
Medical Certifier Name A Title
VA Address 3o I/M� ��. v�Sa .�. 5 S /i '
itjH 0--th Certificate Filed(Th District Number / ( Register umber p
f: r ' Town or Village i,6S�S F " s c) 5 I
Date Cemetery or rematory2 j r
..'`❑Burial //f Zge /C ri".J �r U 1 i✓�
Address
�: emation U 3-1 (4J Q U 6 �C L? UYZ4�- Al
Date Place Removed
'�-'0 Removal and/or Held
and/or Address
r Hold
a Date Point of
"t'Q Transportation Shipment
.zi by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
,,.R Permit Issued to ,� ` Registration Number
Name of Funeral Home/l na rd b. r Ft t bet a/ Home- ono
Address l/ Lafa.c/etc a. , &u.eQ nsbu-rt7i 1)(Jut) VU/k- 1 0g0/
iv Name of Funeral Firm Making Disposition or to Whom
{3: Remains are Ship
ped, If Other than Above
Address
Me r.
Permission is hereby granted to dispose of the human remains described above as indicated.
itc
gt Date Issued 11 ( zSi; 1 i-6 Registrar of Vital Statistics W CA-MYir W-Al\--e•-•
iwi
(signature)
gli
District Number 5 6 0 ( Place 6 (2NA S Ea Us, 0J ki
I certify that the remains of the decedent identified above were disposed of in accordance
with this permit on:
:, Date of Disposition huh 11i Place of Disposition 'll,u Vt:w C`Lrnoto(+J,ft,
(address)
(section) ,,(lot number)( (grave number)
•1: Name of Sexton or Person in Charge of Premises ` ni4 F 31i ittt
F (please print)
Signature a $( Title (i,eif Ailia
(over)
DOH-1555 (9/98)