Nash, Virginia JGt/
NEW YORK STATE DEPARTMENT OF HEALTH •-
Vital Records Section . Burial - Transit Permit
Na First Middle Last Sex
VinnICt.- Dash Ferlyde.
Date of Death Age n If Veteran of U.S. Armed Forces,
- 17 - :9 0 tj -ill War or Dates ti c
Place of Death Hospital, Institutio or �
Z Cites.Town or Village (-,/en - (/5 Street Address Lknc rat 1s �Spi-f
Q Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
O.
Medical Certifier ,, \\ Name+ Title
G ll� 1 1 1 t Q rrN C1ec.V`t,r M 6
/ddress
V O V.- -_ G�.t G 1 art 5 c c1 S N ! Z i o/
h Certificate Filed District Numb r Register Number
(CiVTown or Village iCtIS ra t(S 5 ( 603
0Burial Date emetery or Crem tory
1p- - 1$ -- ! � ?itii \1f43mccry
;;❑Entombment Address
.; ®Cremation t=f 14 CE/15 b u rti (\it\) 114 LI
Date ( Place Removed
Z n Removal and/or Held
° and/or
Address
Hold
to 0 Date Point of
0" Transportation Shipment
G by Common Destination
Carrier
Ell Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home l t 1Ic 4.ev, .rct.,i ac,rya_.. 0 11 q q
Address
r b 6D-A. -78 I holitt." La._tc_A_ Ny 1 IS.1-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ft
I
ii
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j 2) ! S-1 !$ Registrar of Vital Statistics � zi..A. ..
(signature)
<;; District Number 5 go 1 Place 6 �ws \tS 14 Li /t 9c /
#- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
0.Z
tLI Date of Disposition 12-2 3 15- Place of Disposition %,i76 u,`PO Greryj o
2 (addre s)
fil
VI
CC (section) lot number) (grave number)
Name of Sexton Person in Charge of Premises 11 an CD4-frn it
z (please print)
Jt Signature Title C ccn?rvioi
(over)
DOH-1555 (02/2004)