Sanders Jr, Warren NEW YORK STATE DEPARTMENT OF HEALTH 6-06
Vital Records Section . Burial - Transit Permit
Name First Middle
ct.,..tre-A, C , �.,,,.4Lar _st Sex
Date of Death -�'L in
77 / a or�� Age If Veteran of U,S, Armed Forces,
�., Place of Deat ` ��_2 War or Dates L/c '-4.
Z City. Town ilia co Street Address
Hospital, Institution or
w Manner of r
4 Natural Cause Ell__J
Accident Homicide 0 Suicide 0 Undetermined —Pending
WMedical Certifier Nam Circumstances — Investigation
/'tea (...),-s44k
Address �� l
/�V G/ rC,.� C�-a r' r-L-- I i �L_ i
Death Certificate Filed
istrict Number Register Number
i i CitrIlecvn�Village �,P>t, �'f
Dale Cemetery or Crematory
U Burial 7/1-2��0/� /
Address 'ilett,c"' C.t�^
1-Cremation r /- ' )
C3A.�A�I/CJr N L w Yu(.Z
Z ( .1 Removal Date (� , Place Removed
and/or and/or Held
0i— Hold Address
0 Date
Point of
Transportation Shipment
p, by Common Destination
Carrier
Disinterment Date Cemetery Address
Date •
Reinterment Cemetery Address
Permit Issued to
Name of Funeral Home Registration Number
C/ZS,v. r(' 4, '
Address i �G�r�
7 e--►,°..4v ).fir', --P r , .
Name of Funeral Firm Making Disposition or to Whom I°?�dZ
Remains are Shipped, If Other than Above
'7 Address
Permission Is her by ranted to dispose of the human r:r: ••:scribed ov: . .icated.
Date Issued /3/ a''f Registrar of Vital Statistics ' o . , 2
..�•a •re) 4
District Number `IC? ( Place ir,, G,✓ YorrL�
t °
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition /11�116 Place of Disposition QQ
w (address)
0
cc
(section)) 4(lot numbe (grave number)
0
Name of Sexton or Person in Charge of Premises 9> 1* ,0
z /f (please print)
w Signature !� Title /i>�-y,•py11r�
DOri 1555 (10/89) p. 1 of 2 vS 6