Mattison, Howard NEW YORK STATE DEPARTMENT OF HEALTH - % I Z2)
Vital Records Section Burial - Transit Permit
in Name First Middle Last Sex
t4owa'-� LOo0 (VI p-rr so -)
Date of Death _ I
Age If Veteran of U.S. Armed Forces,
O� ('a. I- -° 15 -3 d War or Dates
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Place of Death Hospital, Institution or {�
Sily, Town er c-
Village L►\t- or 1 Street Address C'VSM rti -J� '1
Manner of Death Natural Cause Eil Accident ❑Homicide ❑Suicide riUndetermined ri Pending
RI Circumstances Investigation
'idMedical Certifier Name IN Title
CI I G �� IMF 5 VM
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Address Ft-f.,�`-"'��;n
is (�� � ,� G���s ��� 1 �ia�
gil Death Certificate Filed ? District NumberL��. 1 Register
l: City, Town or Village ` 0 n 7 (l/ l
Date I Ceetery or Crematory
❑Burial d a :�L a� ' Pm
i letU.t e., i C t e."^SV--
Address
®Cremation Qv A 14...0 2_ t 0-a.) Cc N S Y.V 422-v tv `t I a8r CSy
gDate 1 Place Removed
0❑Removal I and/or Held
-- and/or Address
t= Hold
0
0 I Date - - -- - --T—''mint of
N0 Transportation j Shipment
a by Common Destination
Carrier
C Disinterment Date Cemetery Address
[�Reinterment Date Cemetery Address
. 1
Permit Issued to '1 Registration Number
Name of Funeral Home /hard IJ= EaRer Fwiera/ name_ Of 3o
Address // ! ara
V
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
44 Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
'`� Date Issued /-zJ /S� Registrar of Vital Statistics ,4 4 y,
ignatu
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aii? District Number `c;, ' Place !7/)i2ri Q ' / //;1601
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-
Fi Date of Disposition 2I S/I5 Place of Disposition -`l ne U) C n
w (address)
CC (section) jot number) (grave number)
GName of Sexton or Person in Charge of Premises e o
z (please print)
44 Signature A �, Title viot
(over)
DOH-1555 (9/98)