Ladd, Donald NEW YORK STATE DEPARTMENT OF HEALTH # 77c
Vital Records Section . • ` 1, Burial - Transit Permit
Name Fir Middle Last Sex
Date of De Age If Veteran of U.S. Armed Forces, _
et"?/.2 0IS' 73 War or Dates
1 - PIac Hospital, Institution or
own illage�-�, M c.. i,,,� Street Address 1 HkJS.� N.
a Manner of Death Natural Cause Accident 0 Homicide 0 Suicide Undetermined 0 Pending
141 Circumstances Investigation
fij Medical Certifier Na Title
0 j)a.,:GL Lk.rs.. — +7 .
Address /� ' I
G�.re (►wGcAS 4-r i 1 to
Deat . to File... District Number L Register ber
Cit , Tawn or illag � rdk..•ar� 6-7 �4
Date Ceme or rematory
❑Burial / >/a_ /�
, '❑Entombment Address
[ Cremation CQ�,.C.L". ju r N , Y.Date J 7 Place Removed
Removal and/or Held
and/or Address
ilt Hold
CO
0 Date Point of
Os❑Transportation Shipment
G by Common Destination
Carrier
a,0Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Address
Name of Funeral Home e A f.a rt "f , �� .L - O a Y"'r'1r/
Al N r / a p-
Name... of Funeral Firm Makingis position or to Whom
p
}- Remains are Shipped, If Other than Above
;; Address
i
Ill
1" Permission is hereby granted to dispose of the human re ins described above s indicated.
Date Issued1--/0 _is-- Registrar of Vital Statistics
--._ (signatur
DU District Number5>5 Place er.---/
I certify that the remains of the decedent identifie ove were disposed of in accordance with this permit on:
1 .
til Date of Disposition 4(t3II( Place of Disposition futi" Ck,at,
(address)
w
tfl
CC (section) ds,of number) _ (grave number)
Name of Sexton or Person in Charge of Premises zw;" - /M,"`�
/ (p/e se print)
141 Signature �i� Title MAPP
(over)
DOH-1555 (02/2004)