Tripp, William NEW YORK STATE DEPARTMENT OF HEALTH It
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sex .
Mtaiv\ 5 . \VM Cock_
Date of Death Age If Veteran of U.S. Armed Forces,
CA-Via,-�`S ll War or Dates
is Place of Death r` Hospital, Institution or
Z City, Town or Village U�1enS i \5 Street Address beA5 cc�\S -§\TcA-\
a Manner of Death atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ill Circumstances Investigation
W Medical Certifier Name ��^^ r __ Title nn
C)4.v. Q )ck4k tit 'I ' !o.
Address ( CO ew.\C CJ�kx.A \ Cri 6,,s 1 r
,t i 3 , j,s-1 i Z a
Death Certificate Filed District Numbeaog Registers Aber
City,-Town or Village
Ur
DBurial Date s 6 \3 Cemetery or Crematory
\-0-\rz_VkQ._.,..) C... eVoc.›Nvel
:;: El Entombment Address-) /"�
emation \ �.t r,< tC� Asp lX U-Q e v.s6—.A.- \ ri I Z 1
Date Place Removed
0❑Removal and/or Held
and/or
. Address
Hold
in
O Date Point of
EL Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
gi Permit Issued to f Registration Number
Name of Funeral Home 3 \(..a tr -w_t_12 1 _."--C 6V31 1
Address \ Z 3 Ma n 5,t1z_ i' RI- '{ M ( 7
gpi Name of.Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
Permission is hereb gra indicate
Date Issued 6i dS l nted to dispose of the human rema. s described abov -as Registrar of Vital Statistics (rjj�mt� pr -
(signature)
II District Number " c�, / Place Ls4 J
i
I certify that the remains of the decedent identified above were disp ed of in accordance with is permit on:
III Date of Disposition i /(,/(r" Place of Disposition ..gt, Lph..,; ...,,
(address)
ut
to
cc (section) j (lot number) (grave number)
Name of Sexton or Person,J.n Charge of Premises .3
z
4 O please print)
14
Signature (�" Title EoIptpillh
(over)
DOH-1555 (02/2004)