Sampter, Bernard NEW YORK STATE DEPARTMENT OF HEALTH .-� Burial _ Transit Permit
Vital Records Section
pl Name First 0 Middle Last Sex v-
C.t_N PS. - SA,-M VT 1
a Date of Death i _ Age R If Veteran of U.S. Armed Forces,
pc..( (g I aO I5 Ti i War or Dates
14 Place of Death I Hospital, Institution or _
City, Town or Village l Street Address � J tJ S '�A LDS 11 os P IT A L'
N. Manner of Death 1771,12u. Natural Cause ❑Accident El Homicide ❑Suicide EiUndetermined 0 Pending
f Circumstances Investigation
Medical Certifier Name Title
��.c -\- -K N k `iN � A t- 0
<' Address a
ii;liN,O (D Lc_r)S VA Ls-5 `1.
District Number 5 Q I Register Number
�:<�' Death Certificate Filed ff
<� City,Town or Village GL -t S [t L '5 i 1 I `-Vi3
Date t 1 ( I Cemetery or Crematory
> : ❑Burial O-1 l /go IS- P} C . ) k e-\,1 _sz-C rvn Ai D_`�1
Address a�61
Cremation QvNu-GR- CLIDA' 0j-�..>t=C����`�`-\
Date ' Place Removed
n QRemoval and/or Held
and/or Address
Hold ,
Date - -- - -r Point of
Fain Transportation _� __ I Shipment
3 by Common Destination
Carrier
Date I Cemetery Address
❑Disinterment
Date I Cemetery Address
: : n Reinterment
' Permit Issued to / Registration Number
s Name of Funeral Home/avnard b' 'Baker Fu.nercz/ flume 011 0
ii
< Address jl LaFaLlCt-fe Ot. , Gt,4 c ensb nd ; /U Lk- r A- 13 e01
-' Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
ii
IA
iii Permission is he eby ranted to dispose of the human re ains de cribed ab vndi ted.
Date Issued - , Registrar of Vital Sta-st cs gi-e-I. ")-(
r' District Number 6--( ` Place 2 d
I certifythat the remains of the decedent identified above were disposed of in accordance with is permit on:
FDate of Disposition til i4 1I S" Place of Disposition c."id r"^
M (address)
cnCC (section) (lot purnber) (grave number)
Name of Sexton or Person in Charge of Premises --y 1
CI tivIL Z (please print)
i t Signaturejijr Title 01l:r/'N
(over)
DOH-1555 (9/98)