Palmer, Arlean # 66D
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First FiddleLast
Se
�F1e.a rJ a P/me r �A/42—
Date of Death / Age If Veteran of U.S. Armed Forces,
(}Q, or- Vet-5 War or Dates ,() Q
f-- Place of Death �--; Hospital, Institution or
City, Town or Village i ;(... ,uie..-pale—, 'Street Address /f Tom¢ rj -s sh, /47Jo.>
is Manner of Death `� .atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
tij U Medical Certifier e �, // Title
G / A l Lee u tI 5 l .0
A ress
d 1 (<Are 11,0( Rd co,.) S1ti-0 A ,J7 r)oH3
Death Cerl ficate Filed �-�-^ District Numb r Register Number
City, Town or Village ( J Cel'tcC eta, AS q�
❑Burial Date etery or,Cr oratory
❑Entombment 65 7[ Y o tr,ivs--/
Cm IL,ve V 1 w 1, r i 4 10i-y
Address
Deremation t)Q 2,V S t c' Ole' a
Date Place Removed
Z Removal and/or Held
❑and/or Address�
Cl)
Hold
Date Point of
❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home c�wArd �( . ��' F ipi�Af Kc'n,� 055-1 gf
Address ah-Crat
, kilk k 1, e 719
Name of Funeral Firm Making Disposition or toW�hrbm
Remains are Shipped, If Other than Above •
2 Address
t
w
'mii Permission is hereby granted to dispose of the human re ins described above as indicated.
i �
Date Issued Q q-!'-0l5 Registrar of Vital Statistics 1(.-�.„ • G;(l_ _,
(signature)
igi District Number C 5 „,{ Place / 1 dR4' ad ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k 111 Date of Disposition Place of Disposition Roi,U{ir.! G/re'^^r or _
is (address)
tli I itiliC.
CC
CC (section) (lottigumber) C (grave number)
0 Name of Sexton or Person in Charge of Premises G rt:gyp . �J '
2 (please plant)
!44ioiSignature Title 40115J •-
(over)
DOH-1555 (02/2004)