Nolan, William NEW YORK STATE DEPARTMENT OF HEALT ' •1. /MS
Vital Records Section Burial - Transit Permit
Name First Middle Last S
)'li,1a./� 1h(.)alil 5 AIo/an Se
x
Ie.
Date of Death Age If Veteran of U.S. Armed Forces,
3/ 5/ /� 7'7 War or Dates
Place of Death Hospital, Institution Co�r
City, T (i)(or\t t2 a ipe/rcts Street Address 5-if<'a Spil-�./
cf, Manner of Death®Natural Cause 0 Accident ❑Homicide El Suicide n ndeterniined ri Pending
IA Circumstances Investigation
tu Medical Certifier Name Title
' DCW/Ci KOken iYl 6
Address
5 z kq l-a as //a/
Death Certificate Filed District Nut ber Register Number
III City, �or� Sq RL Q Sixl1qs _
f' ❑ / / ��O / /02/
Burial Date ' /�yh Cemetery or_"Crr�em�ry
1 '
>[ ['Entombment r l/ le lbw) L la,aito is
Address �� y
Cremation Qu w
aen5 i ( ) Void(
Date Place Removed
Z Removal and/or Held
❑and/or
F.
i Hold Address
44
0 Date Point of
"'vil Transportation Shipment
0 by Common Destination
Carrier
ID Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to i - /1 _ Registration Number
=« Name of Funeral Home Com J"/(.40 i I-6049"v I L4k[?, .Lnk1. On3( q
` Address
11.0- m Afa, - 4r a 40 5) fagot
: ':.' Name of Funeral Firm aking Disposition or to om
14 Remains are Shipped, If Other than Above
2 Address
ir
tls
Permission is hereby granted to dispose of the human rema cribed aboveas indicat d.
i <' Date Issued �j rf )5 Registrar of Vital Statistics b�} ""s`'
(signature)
District Number 1456 , Place ()., 6F .Sa fi j a o ot(yy1 S
ia I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11.1 Date of Disposition 3//0 f is Place of Disposition ,�,�(1,,, ter.,,..,
2 (address)
iii
to
Cr (section) // (lot number) (grave number)
� Name of Sexton or Person incharge of Premises �'���s ('
(please print)
Ilt Signature Title CIZEPOil4
(over)
DOH-1555 (02/2004)