Kendall, Ernest NEW YORK STATE DEPARTMENT OF HEALTH 4 581
Vital Records Section ., Burial - Transit Permit
Name First , Middle Last Sex
erne-s f- L• X- mea 1/ ,ale.
Date of Death Age If Veteran of U.S. Armed Forces,
/ Qo2. /Q7 9� Waal-
jr... Place or DWaal-
jr... Place of Deat , / Hospital, Institution or
Citytta , Town or 'liar e 6-ra�ta h(/ Street Address` llA / Kibler I / -4Xla e `
O Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ❑Vending
US Circumstances Investigation
tu j Medical Certifier Na Tit.l?g
CI 4 eriy N�
Address
7 ma /c . - 6r,.,,.,v l It . -i lay-
:,..:
Death Certificate . d , I District Number Register mber
City, Town ors. 'Ilan) CI-ram(J i 11 e 5 .
❑Burial ate Cffnetery or Crematory
// 06-7A /e✓rete efeaa
r / Citee4shiery A/l/ (nal❑Entombment ,
Addr s
Cremation )1)j,_ie ens k2u r /� i <01
Date Place.Remo ed
-
2❑Removal and/or Held
and/or
F*� Address
Hold
0 Date Point of
t Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home `.'J 6f$rno re_ run cal ./ tO r
Address
I S-tierma„ Ae 'r,''i*-`i Air j a-f�c)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
III
CL
Permission is here y granted to dispose of the human rema' s descr' abo as indicated.
Date Issued �'/ S- Registrar of Vital Statistics
(signature)
District Number 5 7d5 Place Sri dilfi" iv
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition ii/b/i2. Place of Disposition 4? QuQ Cry-rtoriV".-
2 (address)
ILU
ta
CC (section) (lot numbery- (grave number)
12• Name of Sexton or Person in Charge of Premises A,,ykli....,
1"-e�+2+ (please print)
• Signature �� Title e124E MK}iv
(over)
DOH-1555 (02/2004)