Lonret, Sharlotte NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
11.0 Name First Middle Last T I Sex 1-.-
'fig S r-k AR_L-0-71- 6 Le G L_o sA sz_C
Date of Death [Age If Veteran of U.S. Armed Forces,
ii0 la21S- , 41 War or Dates
'':•':,!! Place of Death
City, Town or Village ( t..f.-:t-- s VA t._‘..-S
Manner of Death Hospital, Institution or
. Street Address Gt-t...'71--"S fis-LA_s
Lrz-A Natural Cause E Accident n Homicide 0 Suicide ts. .ss?n A (--
n Undetermined ri Pending
Medical Certifier 11-- Name , Title-- ' 'Circumstances '''-'Investigation
VP Address
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O. Death Certificate Filed , T-District Number 7. 1 Re17,1er
City Town or Village (._. LE t-s s riN L-L.S -CLO ( I M
.... Date 1 Cemetery or Crematory
E]Burial (c, 1 tk / ,C)i-S-"
Address rk
Cremation l...)2.0 A,..kLeca ti--!D 6.:,›C.E.),-)Suc.2-`"1/4 tt-)L.\ t a 804
Date , Place Removed
Z I—I Removal ! and/or Heid
wil—i ,
m and/or Address
.7-7. Hold
ti) — — ------
0 Date : Pciint cif
010 Transportation I Shipment
~ -
a by Common Destination
Carrier
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Date 1 Cemetery Address
0 Disinterment
--Date : Cemetery Address
ii Ej Reinterment
Permit Issued to Registration Number
it. Name of Funeral Home Ha/110 id 6, 6aite1 Fi_trie(01 Home_ I
; CI i
Address
/1 Z.-araLl CttC7 3+. , a ULU')S ba"-j , A J eA,,,) Lifo. r It / YO-1
Name of Funeral Firm Making Disposition or to Whom _—
a Remains are Shipped, If Other than Above
Address
,li
Permission is here y ranted to dispose of the human remains descri ed ab7, as i ed.
in 1‘,/
Date Issued 6 /./ 20/J Registrar of Vital Statistics
gl (signature)EV District Number S----&Of Place _ ‘44--'. AX A /ux
.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Pi!
EDate of Disposition (0-Q-15 Place of Disposition 'Pyle tic'ew Crervidori!cull ______
2 (address)
114
go
f:C (section) (lot number) (grave number)
2 Name of Sexton or Person in C rge of Premises T 1)4-4 y ' 11.'UP1 fliC
Z ii -.V.^4 (please prirto Signature Title Cre AN ek or., 45s 4,
....
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DOH-1555 (9/98)