Andersson, C NEW YORK STATE DEPARTMENT OF HEALTHs 3 So
Vital Records Section Burial - Transit Permit
Nam ,, First MiddleA i Last Wile_
. ' OYG1 Id 'ale:.{ 55n() !►•ale_
Date of Death Age If Veteran of U.S. Armed Forces,
5 IS-- ZQ((p Loa War or Dates Nj0
1.4 Place of Death Hospital, Institution or
5 City(Tow or Village 2.14 G�d C 4 ifr 28C
I (,�Ian �;��� Street Address i
Manner of Death r Natural Cause 0 Accident El Homicide 0 Suicide ❑Undetermined Pending
W. Circumstances Investigation
Medical Certifier Name Title
i it)le I (\►(L1 M.6,
Address
I►r V U e NN/
Death Certificate Filed � Districtt Number Register Number
City, or Village I YYI l i v LcL 2. c j
0 Burial Date emeter(or Cre atory ,tom.
❑Entombment • Z 3 ( (O ►v V i C.a) � m CC t 1.'n
Addr
%Cremation LIP.t•`Frloh(.i-R f
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
F=" Hold
in
0 Date Point of
er..Ei Transportation Shipment
2.s by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 11\,I Ior 7.y-,7, &I J--ki - 0/1 6 -I
Address 3(0 '7 3iCi -c.—at 30 1 ryi 1 C4y) Lcu /�� i 2 g 2
_.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
cr
„La
' Permission is hereby granted to dispose of the human r ins described above as indicated.
r
Date Issued 7 i// 0 Registrar of Vital Statistics L,.,.(...<.-; l i .( a( i 7
(signature)
District Number 7L,<, Place i 1)Lf1;rLi,,
I I certify that the remains of the decedent identified above were disposed ofof in(►accordance with this permit on:
p N`i' Disposition ?C .e V..1 �i rcw--
Ia Date of Disposition S-2 Place of
2 (address)
Lu
Cl)
cc (section) A Clot numbet� (grave number)
Name of Sexton or Person in Charge of Premises 4rtrtpL cam\
2r ( lease print)
LEA Signature L( Title f2VAIAL
(over)
DOH-1555 (02/2004)