Harrington, Wendell NEW YORK STATE DEPARTMENT OF HEALTHell � ✓i Jo Vital Records Section Burial - Transit Permit
pi Name First Middle Last Sex
\ eA }�wr��in-on
Date of Death Age i If Veteran of U.S. Armed Forces,
r 1� ` l5 I I I CO y 1 War or Dates
... e of Death i ! Hospital, Institution or 1
GA ens 3 \ E X,)\ I Street Address V. r�
� own or Village S G��� �1`� '
Al Manner of Dea Homicide Suicide Undetermined � � ending
t{L Natural Cause ❑Accident ❑Hom c ❑ ❑ ❑
f �-'� Circumstances investigation
Medical Certifier Name Title
r-c; `Csoa ;o 114-i - &n-X S 1-\
• Address
<> (0 2- Pa r84.-S} G{2..•c\5 --'ao\s &U`� I d I
>� Death Certificate Filed ` �- ! District Number j Regist
..,.
'�x Town or Village eClS C�1 W`- I I i ��-�
4 Date i Cemetery or Crematory
!
Burial 11 L 2-o l j !, Pine_ \l i n/3 etnallor
Address
:?: ®Cremation i NO r D
Date ; Place Remov
El Removal ? and/or Held
and/or Address
Hold
0 i Date i P‘;int of
fril rJ Transportation j Shipment
a by Common Destination
Carrier , -
Date ` Cemetery Address
ii 0 Disinterment i
Reinterment Date Cemetery Address
Registration Number
>� Permit Issued to �
' Name of Funeral Home Balker �u \efttl �oMt.. - i 0\\30
im, 1
Address
'�11 a Ni Skree-}- Q vseenSloik i N`t 1 Z'OL}
SI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
is-
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i I 1 l 2p i5' Registrar of Vital Statistics W G . A. ‘-A1�`-�r
kTr
(signature)
iMi District Number 3 b4 Place 6 CsA/NS \--, i P
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
sti E Date of Disposition Nil$Ml c Place of Disposition KtC,--,,wt
2 (address)
w
In (section) (lot numbs (grave number)
D Name of Sexton or Person in Charge o Premises It.
r,j 3 wAct
G (please print)
Signature A Title fti1fin
(over)
DOH-1555 (9/98)