Beaudet, Clay ` # 52
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name First Middle Last ^l e Sex , i
CI CAS ��nk) OCI t-).,
Date of Death I Age " If Veteran of U.S.Armed Forces,
C�7/Zb J ZO)l.0 7 I War or Dates i q S 9 — 10 1D
.::;;:. Place • i.-- I Hospital, Institution or
City own ,r Village Street Address q eih CO-C, \S\a-a a A J e ,
Manner of Death[Natural Cause Accident El Homicide El Suicide nUndetermined n Pending
Circumstances Investigation
til Medical Certifier Name Title
Address J
LIroa cl �S�- l�v f=a. ,s \‘s \( 12801
:;:, Death to Filed District Number R t Number
City own r Vdlage 1�P Yl;��t)c -L9 S Y
<« ❑Burial Date ( Cemetery or Crematory
['Entombment O� Z Lo ) 2-o) LQ Pi \C vJ CA 0 \as-a-,-/
is Address
igii Cremation Q�?-2Q,ns\( ..c , j \c,)
Date / Place Removed
❑Removal and/or Held
for Address
Hold
s' Date Point of
t3 0 Transportation Shipment
by Common Destination
Carrier —
111
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Halnard -D. aker Funecct( Horne O t t to
- Address ' La-rave-He Si-ree Quee Cl sbul-y , New Vor- K la $°Li
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
iti
ix
Permission is hereby granted to dispose of the human re ains described abo as indicated.
it Date Issued 11 `Z I � egistrar of Vital Statistics C-, C ` "J\ -.--___^
(signature)
-> District Number SCE S l Place Cd u.___.(-\ of, C.Q
I certify that the remains of the decedent identified above were disposed of in accor +wefr. this permit on:
Date of Disposition 71 flub Place of Disposition �� �t✓ �r �
tll
(address)
10
(section) number) - (grave number)
IIName of Sexton or Person in Charge of Premises rtpi- �i"'"rt
Z (t Pint)
Signature a Title C'etM
is
(over)
DOH-1555 (02/2004)