Carlson, Charles s
S5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirbhcLrk
Middle Last Sex
& W e ,..,Last son i4, ,(e
Date of Death TAgeQ If Veteran of U.S.Armed Forces,
f:,1 16I ?o I(o 1_— l 1 War or Dates 15Yy y.�
Place of DeathHospital, s!�1ir.'• or /� n
W City,T t n3r Village Cv/On j e. Street Address .t obt1.b.�1g,, 1'�SSvS1 1l.1,*n9 0-is.
p Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined El Pendtrig
Lai Circumstances Investigation
us Medical Certifier NIrne Title
CI1#\rts+\ri earr,to agnc, *bO
Address-9-/3 Troy SelkeiNectrA a--• *24 L %-zm, N -1 121 )O
Death Certificate Filed /,! istrict Number Register Nu ber
City,T ®r Village CEO/Oht(. f5. gJ
❑Burial Date Cemetery or Crematory
DEntombment I/9 2�I Co i ine, View Clem eVori
Address
Dicremation 7- 1 O.vaLicgr Psi. bG , my / / of
Date J Place Removed f
O❑Removal i and/or Held
- and/or Address
Hold
^+++ Date I Point of
N Transportation 1 Shipment
a by Common Destination
Carrier
Disinterment
Date ! Cemetery Address
Reinterment Date 1 Cemetery Address
Permit Issued to r Registration Number
Name of Funeral Home �is 1'f them funeral h Orv�. 610 19
Address
$2 3 road UJCvA Vor+ Edcc arc tii !w
Name of Funera Firm Making Didposition or to Whom
1= Remains are Shipped, If Other than Above
2. Address •
C
W
CL Permission is hereb granted to dispose of the human remains described above ove as indicated.
Date Issued ///f /(p Registrar of Vital Statistics _ �. e"--"Z-a-
(signature)
District Number /53 Place � X O / C/'z .-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I/Z1/1% Place of Disposition gr vex, 61^4trit ,
12 (address)
N
gj (section) (lot nurfber) (grave number)
p Name of Sexton or Person in Charg of Premises ifs . t
(please print)
us zt
Signature Title f -afill.
(over)
DOH-1555 (02/2004)