Wells, Marshall NEW YORK STATE DEPARTMENT OF HEALTH # iL'
Vital Records Section Burial - Transit Permit
`,
Name First iddle Last Sex
c''< kJ
S _ eJ 'V (�e2C✓1 i� /ftitir
Date of DeathI Age , If Veteran of U.S. Armed Forces,
3 Li ffj_ I Si. " War or Dates (,,.)i;J IT
Plac of Death ' Hospital, Institution or
C. , Town Village G) U d S a Uy Street Addres 2 ti rh,,w(5 d jj 32 ,
E. Manner of Death I5 Natural Cause 0 Acci nt Homicide Suicide Undetermined Pending
f Circumstances Investigation
Medical Certifier Name Title
, � �& Go M0 OA 0
. Address,
"': Dea icate Filed Dis rnber I Regi�ste`r�umber
Ci Town r Village U a U I
Date �/9-c)(
� I Cemetery r Crematory❑Burial J ! r1,.) U/6,-,..�
AddresszTh
Q
Cremation .-.)A WC tt D a ,=�..' o E N 6v'`* (2 sc
Date Place Removed )
g❑Removal J and/or Held
�-. and/or -_i--- ---
};: Address
Hold
0 Date - - -- - .pint of
N0 Transportation j Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date I Cemetery Address
-' Permit Issued to Registration Number
A> Name of Funeral Home Ha yna rd b: &titer Funercz/ Home_ 0' ) '()
iii Address
II l i Lra i e . , b c,te.e.n sbc c.rc ; A eLL) L/or)t I J eol
.>.<. Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
Address
4
lb Permission is hereby granted to dispose of the human r mains describedlabove as indicated.
Date Issuedi'1(se.L3-0/` Registrar of Vital Statistics C� j3 xu—__
7_, (Si nature)
>: District Number S j Place t� �S —,� �,
I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
F,,EDate of Disposition 3llollS Place of DispositionKiii-0,,...
W (address)
Lr (section) (lot,numb ) (grave number)
GName of Sexton or Person in Charge of Premises tL„ram,. �uGv�
z (please print)
441 Signature 44 Title CIWAVIL
(over)
DOH-1555 (9/98)