Mosher, Delbert r 1
NEW YORK STATE DEPARTMENT OF HEALTH /.,�
Vital Records Section Burial - Transit Permit
Name First M'ddle Last Sex
�GLI, r4 ,�, f" 105�i� /v
Date of Death ,, Age If Veteran of U.S. Armed Forces,
i 71 L /dal s'.----
6 War or Dates I1`6K— /173
}..., Place • Death Hospital, Institution or
Z Cit, own or Village 6:9 f• Street Address 3 1c Cam• f / a
W M.h••4 • Death 0 Natural Cause 0 Accident 0 Homicide E Suicide ri Undetermined pi Pending
Circumstances Investigation
W Medical Certifier NameAVA\ c. 1/ Title
Cl
Address
S. - 3r,-,9: * (-)'0-P•. r& tv- J ) `65
Death ficate Filed /- ._.. District Number/ Register Number
atown r Village C_,.3 r � 4f5-53
Date Cemeter or Crematory
_ Burial I /a,-� 7 (,,( :1e V,c_L—..)
Address t�
fYlCremation Qei Ult-4Sjvr U�, !t,r &
Date i Place Removed
ZO Removal and/or Held •
I and/or Address
c Hold
O Date Point of
0 —
Transportation Shipment
n by Common Destination
Carrier
Disinterment Date Cemetery Address
— Reinterment Date Cemetery Address
Permit Issued to _— Registration Number
Name of Funeral Horn 5M.7r-cN.A.N. rt ( /4-4cf .11-i -- Oc' 'V
Address
Name of Funeral Firm Making iDissposition or to Whom
t Remains are Shipped, If Other than Above
Address
CC
tLL •
CI:
Permission is hereby granted to dispose of the human r a ns scribed ov s ' icated.
Date Issued 1 /i 5i Registrar of Vital Statistics sue— X.4/( ./
a re) /
District Number�'t'Ss3 y
Place Cr• .. / lllc✓ or`�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition f'V3- IS" Place of Disposition -FAI / Cr .41or;w.-
(address)
w
CC (section) /� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises G"rarfi , ,Se+
Z (please print)
W Signature Title CILE AWie..
DOH-1555 (10/89) p. 1 of 2 VS-61