Wood III, Theodore NEW YORK STATE DEPARTMENT OF HEALTH Zb
Vital Records Section Burial - Transit Permit
Name First__ Middle Last I Sex ,M
INE07o�� C E. \J�� Inj 1 ' 1
>' Date of Death�/3/aO Age If Veteran of U.S. Armed Forces,
LS- War or Dates
Place of Death I Hospital, Institution or Z City, Town or Village j Street Address \ (o- t q Lk 8
Manner of Death ii ,Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
iti Circumstances Investigation
Medical Certifier Name Title
c.. PA L)L. t- C-►1ra A r
i .4 t"1)
Address
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. 33-L 111 Ai t-. S r P Os ( 2v , ii`-k ‘04.8 5
<; Death Certificate Filed District Number Regis er Number
City, Town or Village blu e,E N.5 i)v�`-� S L 51 L1 9
Date ^,metery or Crematory
❑Burial /LI I 20( S ; - ,‘ `7 r-�_rtiv\-- ATE t`"l
Address
EaCremation 0 vt+.k./.__E-R- j L.)t;t..I-3 S =Z' (D�°
i Date i Place Removed
0 Removal ! and/or Held
In and/or Address
r= Hold
0
Q Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
lig Permit Issued to ;� _ Registration Number
>1 Name of Funeral Home . /4tt;�( J--.;.01. / AY On j 39
p? Address {`,
i/ i)- L-TTC- •)i . Ub22 .oS 6i U t'�.c %U / '-c3 ti
Name of Funeral Fm Making Disposition or to Whom ,• I `
Remains are Shipped, If Other than Above ��
Address
J
f
Permission is hereby granted to dispose of the human remains described above as indicated.
<i Date Issued LP l sI ao+ Registrar of Vital Statistics
(signature)
District Number.np 57 Place �V z_ c r S loU�
I certifythat the remains of the decedent identified above were deposed of in accordance with this permit on:
W Date of Disposition L1 gllr Place of Disposition fu Li Chat
2 (address)
ttJ
CD
CC (section) t number) (grave number)
i
Name of Sexton or Person in Charge of Premises • tkgrb, �. to
z (please print) J(
W SignatureZ Title /i'uv'fThtt-
- (over)
DOH-1555 (9/98)