Alden, David NEW YORK STATE DEPARTMENT OF HEALT i` I-3D
1.
Vital Records Section Burial - Transit Permit
Name First 1 Middle91)i 6 --S /9-,Co,.- ., Mt)e--;.) s
eL
Date of Death Age r, If Veteran of U.S.Armed Forces,
2 /L/ l6 (p War or Dates ( — •
•
- of Death a-1 • 1, ; lion or
rii:sown or Village CI L,i�.,r3 Fel&J / Street Addr- : s--1 3- C q c r;',,) {;
Y anner of Dea i \r 4'Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
WI Medical Certifier Name Title kb
Address �a F
�� )�0r ) A i ( tduS r ,5" I2,d/
- Certificate Filed , c--- District Number Regis4er mber
( own or Village L+,A/a ,,._9t.L —._5 fN 1 .1
• ■Burial Date Cemetery o Crematory D
0-3
«; ❑Entomtxnent 2% /6 i(, r 4,-
Address t
'I C1 Cremation C) U 6 , ( t U b'?5-jt)s a „r��/C/ /L'o
Date Place Removed
--.1❑Removal and/or Held
and/or Address
Hold
Date Point of
s Q Transportation Shipment
by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t_+cky flat d !7,.fkaer Fkineroj f.ko rr\R_. Oil3 0
Address
I I Lcx-f-ckyt-H S. , Queensbusv , N e ves "juT IL 12 S?0 i—
< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
1,-- Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/1 6 //6 Registrar of Vital Statistics (it.)c u2iry..x, -/
(signature
District Number 5 601 Place 6 (.9...10...5 F-e,& ‘ \ S� IV L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LA Date of Disposition .11 11�� Place of Disposition ,,,r,L rw ervirc-(oc 4.--
i9� (address)
MI
(section) it (lot number) (grave number)
Name of Sexton or Person in Char a of Premises is, I'" -�4'''sr'N-
rjplease print)
Signature f,-C Title rT -
(over)
DOH-1555 (02/2004)