VanGuilder, Joseph NEW YORK STATE DEPARTMENT OF HEALTH 4Itr
Vital Records Section Burial - Transit Permit
Name First _Middle Last Sex
SoSeph E E . \IAnbtAttder file,
Date of Death Age, If Veteran of U.S. Armed Forces, qe5
-aO--,9415 69 War or Dates 191414-- i.j q
Place of Death Hospital, Institution or 12-es'i.c ice
CityS j or Village \j\}h't�eha.l I Street Address a°�a t, ('caw 44 Ip,k4-e Li
IliManner of Death®Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
01 Circumstances Investigation
W Medical Certifier Name Title
aX CI O SS man f1 tJ , roe d L ea l b the
Address
5 ?Du.1 -ney }ree-j- )Lvl�)ke..hat 1 i N Ni is 3'7
Death ificate Filed District N imbJr Register Number
City Town r Village V V)01 eJThO i 1 $r1 CQ Lp 1
❑Burial Date emetery or Crematory
❑Entombment a-, 5--aoi5 kcne view' CYemct-1-Drilli -\
Address
Cremation own O-P 6C1,,keenSbcLrl{ ) Me vv "1df k
Date Place Removed
Z Removal i and/or Held
9 �and/or Address�
U) Hold
O Date Point of
❑Transportation Shipment
O by Common Destination
Carrier
D Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to 1 _ Registration Number
Name of Funeral Home 111SOn �wme r a.4 kbrn r C- (,O$$c
Address,
)40 LOt11tam5 -rf' f- Wh14-eha') )•1y Iasi/
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
LU
'; Permission is hereby granted to dispose of the human remains described aboveve as�indicated.
Date Issued Registrar of Vital Statistics a - I^i 1ateij l
(signature)
District Number 5 .g II Place-1-t5 Y� e,-c VJ fie.h
'fa.J t 1` w,l by r�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ta• Date of Disposition 212111 s Place of Disposition giU.--.`
2 (address)
Iii
11
CC (section) 4 (lot number (grave number)
0 Name of Sexton or Person in C ar a of Premises 3,
gg
�*�� C/� j ( lease print)
Signature /� Title Caitiff f 't
(over)
DOH-1555 (02/2004)