Larson, Virginia NEW YORK STATE DEPARTMENT OF HEALTH. _ Pit/
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
YI �'Daiii
te of D ath �, Age If Veteran of U.S. Armed Forces,
`0 /6�A rl War or Dates
}- Place of Death ..--- _ Hospital, Institution or
ii City, Town or Village /1<..o A1 4,:. EV Street Address /j is i21c 1 '
at e.,6 , ,Ivf 4A1
Manner of Death QNatural Cause ElAccicak-:it ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
In
Circumstances Investigation
til Medical Certifier Name Title
Air1CS 6AL( l �l.. Pihr
Address
Al /r W. C-i 1-7�- S. �'G0 r4 4 6r? ail i ,
Death Certificate Filed (.----' District Number it-- Li Register Number.
City, Town or Village it f i A ,PA, GA
LAO
❑Burial Date Cemetery or Crematory
60/ ii/ /-.„6". Pl-i46-ti r Cf.: (
pi['Entombment Address
remation a UL^f/tS /3 .rzy lu,
Date Place Roved
Z Removal and/or Held
9....❑and/or Address
to
Hold
0 Date Point of
ilW Q Transportation Shipment
. by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
„; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above A 1� ) l t-OZ- ` k, �fir✓I;L.Y I R' ,71,j L eit I- rlui
Address
tr S CA4 0.0 o% tit L t k t:- Nf 'a 'fo
us
Permission i ereby granted to dispose of the human rema' es ribed abo s i• •i =t,d.
Date Issued'' Registrar of Vital Statistic ✓/� , c/2----__
(sign=
District Number ed4 Place _ 0
I certify that the remains of the deceden ified above were dispose. of in accordance with this permit on:
tii Date of Disposition if/lair Place of Disposition g J ✓ L +JCat s m
(address)
111
CC (section) i flot number) (grave number)
0
0 Name of Sexton or Person in C arge of Premises T1fi4. Stnnt
Z (please print)
Signature Title Tpit_
(over)
DOH-1555 (02/2004)