Holden, Frederick NEW YORK STATE DEPARTMENT OF HEALTF 'I ,
Vital Records Section Burial - Transit Permit
Name Fir5j Middle Last Se
RE 0 E(Z-\ C.Y.- \J-D-1/4 1 vun 1-\oL--7L t3
qi! Date of Death Age If Veteran of U.S. Armed Forces,
O i I t % i 'C,0 q It' War or Dates —
• Place of Death Hospital, Institution or
Gov M Street Address S �k o
City,Town or Village Qv�e��
Manner of Death2. Natural Cause ElAccident Homicide ❑Suicide ri Undetermined n Pending
ILI
Circumstances Investigation
gjj Medical Certifier Name Title
5�.o,�c. Ste,."h0". N C'
S)3 Address �} (� \ ` �}
id \ _G r-t \ �\OCA JtC r.s\Jv r NL'\ \ a OZ)4
'. Death Certificate Filed Di ict Number R ter Number
iti City,Town or Village a v-e Q"N�bv r- (.00 eTh
<<s❑Burial Date / Cpmetery or Crematory
` '❑Entombment Address
Pi Cremation Q uc\ .a r c .0 act Q o e_e_se‘s\,-,r s r i�`--k l a%
Date Place Removed
❑• Removal ` and/or Held
and/or Address
ftt Hold
V
KJ Date Point of
Transportation Shipment
t by Common Destination
Carrier
::: Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
iiiiijRi Permit Issued to m } Registrati Number
i Name of Funeral Home 1 C.��c,r `J cks R-`^ ccX Io'"^�
Address'` Lc.CG --�-1 ace.vx s�.,f\ { N \ t(1..® O 9 .
10 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.2 Address
IX
Its
Permission is herebyb granted to dispose of the human remains described above as indicated.
Date Issued I I?O)ob) 'Registrar of Vital Statistics+ c_ E A (ti.._
�—, (signature)
<' District NumberS(c i'l Place k O -\ ac (r_
P
'`, I certify that the remains of the decedent identified above were disposed of in acc danc with this permit on:
1� Date of Disposition I hi I is- Place of Disposition go. La Lri-e7 .
2 (address)
l
fil
a (section) 4(lot number) (grave number)
ei (j
Name of Sexton or Person in Charg of Premises h" 1- �_p"
ior
(phase print)
!t€ - r / Title C Plii
:<:: nature
(over)
DOH-1555 (02/2004)