Caprood, George NEW YORK STATE DEPARTMENT OF HEALTH, �31
Vital Records Section -; Burial - Transit Permit
iiiiyi Name First Middle Last Sex
'aG- Laprood 1-1)
Date of Death Age ( If Veteran of U.S. Armed Forces,
O`i 12-7 1 2w t.* _ Loy. 1 War or Dates N ) A
*4 Place of Death Hospital, Institution or
it Town or Village &reins- pet 1HZ-- Street Address Glens FA\\5- Hos ;4-a
)
Manner of Death Lat,Natural Cause E Accident Homicide �Suicide Undetermined ��Pending
Circumstances Investigation
yi Medical Certifier Name Title
Address
l 00 Pa rK- (S -r'r G{-Qr)�S•" fa ))I s, i y 1 e-Pol
>` Death Certificate Filed District Number 6 Register Number
`. C own or Village G1,.e n S- p )1 c J�
I Date Cemetery or Crematory
>: ❑Burial 1 ogi ( 29 ) ZO)tQ 4);r& v ,euJ G'mc.L+o"
Address
gCremation Q ue..enSbv+n1 f N\J
Date 1 , Place Removed
. Z C Removal f and/or Held
ri and/or Address
Hold
Date Point of
N Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
E Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeMt,--
Address
/1 �i L3 ,�— Cl", 1)6::Ns >'Scar 12.E t
' ' Name of Funeral F� Making Disposition or to Whom i
igeRemains are Shipped, If Other than Above
.w. pP
l2 Address
4
Permission is hereby granted to dispose of the human remains described above as indicated.
li
Date Issued 2-•1 J 2 cf /20/6 Registrar of Vital Statistics �J� W .1"' 4
If
(signature)
im
District Number Soo I Place G CQ S Vcn 115 r�f y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li- % (4L_1
Date of Disposition 5131r� Place of Disposition r
2 (address)
tU
(13
fl (section) (lot umber�,� (grave number)
Name of Sexton or Person in Charge ofremises rol �:'' 'I
(please print)
1:t1 Signature1/471
Title CiNkiktg
- (over)
DOH-1555 (9/98)