Pike, William ;ter
NEW YORK STATE DEPARTMENT OF HEALTH �y
Vital Records Section Burial - Transit Permit
Name First Middl Last Sex
(J 11llam A Iike, Male_
Date of Death Age If Veteran of U.S. Armed Forces,
q- 1 -- Z015 -72_ War or Dates &Ip
1- Place of Death Hospital, Institution o 1-Jos
Z Ci , Town or Village Gl 5 et 1 IS Street Address G ��)S iS j i
-k--4 s
. Manner of Death N Natural Cause El Accident 0 Homicide 0 Suicide riUndetermined El Pending
111 Circumstances Investigation
ill Medical Certifies Nam Title
ti rG i k o 6rti hk s Mb
Address
10-Z Rir-k St GIeJos 1 )2& /
Death Certificate Filedr District Numb r Register Number
Town or Village ( te,n5 t I I.S 5,06) �
ID Burial Date ,C(�emeterry/or Crentory
❑Entombment Del (081 � IS PL.ri V 1 e� mc,1�
Addres
WCremation lk-U.41W bCk r9 ,/I
Date 'Place Removed
Z ❑Removal and/or Held
and/or Address
41.,fl) Hold
Date Point of
05 El Transportation Shipment
el by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to i- � I Registration Number
Name of Funeral Home5riD�( rl�. )Q rat ! Dryti, I hc.. d��i
Address
ai+ u--c-h St Liu L Z Q 7 / ►2.$4-iP
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t1i
'` Permission is hereby granted to dispose of the human remains d scrib a ve icated.
Date Issued Of�0�/2o/.-Registrar of Vital Statistics
(signature)
District Number 5 / Place ‘4—.4 r Vh, Xv/
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
+1
tr> Date of Disposition `r I hl(S' Place of Disposition ?AL L.. �ra►wctorio.
', . (address)
t:
C (section) //��. (lot number) c (grave number)
Name of Sexton or Person in Char a of Premises Ghrs( lease J0Hq
print)
Signature �"` Title iiA
(over)
DOH-1555 (02/2004)