Pearsall, Richard NEW YORK STATE DEPARTMENT OF HEALTHH i La
Vital Records Section Z
Burial - Transit Permit
Name F' Middle t Sex
NLAtiard Ph l 1 1.prsc l 1 M
. Date c Death Age If Veteran of U.S.Armed Forces,
A.ry e 3o 20 t 5 �� War or Dates I qy 3-1gyCo
P ce of Death I Hospital,-InsfituttrffW
C 6-i&'ic ra-l+f N-7. -Sif+eet-Address u S FC kOli1
Manner of Deaatural Cause 0 Accident El Homicide 0 Suicide a Undetermined Pending
Circumstances Investigation
Medical Certifier Name tijen S tnc A q' Title u . P. _ C
Address 1 q -- •) eit,sul S i-0.A l s r pq 1nQ 1
D Certificate Filed - Reoister Ni sifter
Date r4_1 2� 1 Cemgtery or Crematory
:: D Burial ` 5
ill rl r View C.ce r aj-6 rt
Address ��
remation tit Viaiki r lke,e 1 - Atzu v k_
Date I Place Removed
Z ri Removal and/or Held
F an or Address
55 Hold
Date Point of
Q Transportation _ Shipment
3 by Common Destination
J Carrier
:::::Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
•
. Permit Issued to Fc- -e Registration Number,
Name of Funeral Home Ha ynard b. ker cc-i home- 01130
A}' Address lI La:rat-i e (5+. , &UlfnSia-l-rid i JUe.IA) VOCA- /QRY-1
Name of Funeral Firm Making Disposition or to Whom
X Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human tremainsdescribed above as indicated.
Date Issued) 11i Registrar of Vital Statistics
�{signature �
District Numbei -g )) Place, 6 ��' C 1 s f y
- I certify that the remains of the decedent identified above were disposed of in.accordanc with th' permit on:
1 +� �
Date of Disposition !`v7_/.. Place of Disposition of e u,e`-,i Cron-44dr.'t Jh 1
A (address)
U1
I& (sect) (lot number) (grave number)
GName of Sexton or Person in C ge of Premises 1 i 4,n f:,lru ne &
Z — (please print
4c.
Signature Title Cre►�4j S
(over)
DOH-1555 (9/98)