Barber, Wayne 35
NEW YORK STATE DEPARTMENT OF HEALTH 1 Burial -�ransit Permit
Vital Records Section
giiiii Name First! / A 4 MiddleLast rz Sex p u`"'l
�/(�I rCIS
Date of Death Ag�e If Veteran of U.S, Armed Forces,
05 3b �- -t )6 A Z- War or Dates
Place eath �/� , L 7 Hospital, Institution or y�,� J
Ci , Tow or Village 04 A 1D 13 Street Address I"t/VA M1RcrI
Ma r of Death Jatural Cause ❑Accident ❑Homicide E Suicide ❑ Undetermined Pending
Circumstances Investigation
in Medical Certifier 1 Name e5- N.
LUDO S perRDop atz-iG Pt-t_faitcw, KJ/
fl_V 1�
.!:;iiiiiiH
Death Certificate Filed District Number Re ister Number
City, ow�,dr Village �I� Aryl-To tJ i 5-I 1 CO - 1 I
;. ❑Burial Date etery air prematog)
iiiR QC0 -d I -i-o I IP l N V' 1 F-ui (�tZ w►ie rc;MY'
Diltmbnient Addre , /
; ' Cremation 2( � Iz. Pb, �� ►� ios-GkiR�� MY 1 l7
Date Place Removed
❑Removal and/or Held
and/or Address
CA"` Hold
l Date Point of
Transportation Shipment
3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
;< Permit Issued to At+-44sqvcre4z.
�- � Registration Number
Name of Funeral Home hJ .) E� .. )
,{.k, ohi� 00°31
<€ Ad e s / r
Ai
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
CC
Permission is hereby granted to dispose of the hun an remain described a ve as indicated.
liii Date Issued 5/3f II IA Registrar of Vital Statistics
Iiii
`-- (signature)
giii District Number S t Place 1 csw D1 Lha-✓ (-{- -v
4... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili
RAU,..../• Date of Disposition y if ll6 Place of Disposition �,�... ��
(address)
w
CC (section) /7 (lot number) (grave number)
Name of Sexton or Person in Charg of Premises `'Ih► �� Jiw.adA-
"; (ease print)
IP (ISignature Title air kW
(over)
. DOH-1555 (02/2004)