Garrand, Albert ov -
NEW YORK STATE 1 ARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name i 1 Middle ash i ex7
F
Date ofDeath IL
0 !5- Age If Veteran of U.S. Armed Forces,
War or Dates /W
Place of De- , Hospital, Instituti�
City, Town o illage �� �°, 4, Street Address �- , i'SL)
Manner of r ea • �� Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Ul
Circumstances Investigation
Lit Medical Certifier � Tim„ o
ici; A‘li; 1
,3 restrit -- M/ 1A).1 (fix ;c L )
Death Certificate File L District Nu e�� Register Nmber
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City, Town or Village -t'l
❑Burial Date �0 jc�//� Ce e/4leery4ao_Vjeeg-e7/402/
����Entombment Address� �.�
"Cremation
Date C.� Place Removed
Removal and/or Held
and/or Address
Hold
-- Date . Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to } T Registration Number
e 4 Name of Funeral Hom ,Law- l/_ a
Address eaR
7 -4 -b
- W X2)
Name of Funeral Firm MakingDispositi n or to Who
Remains are Shipped, If Other than Above
Address
i
Permission is he by armed to dispose`of the human r • s described above a ndicated.
4. Date Issued ,� / Registrar of Vital Statistic ,e."121
�., �^
District Number fPlace h,I a� ii/eigt;:inature)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition iz-tc-/S Place of Disposition �`�;,,, 014,1 6.rp,„4.�®iv
(address)
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises --,� j,-,--r 6e-mo4 .
Z (please print)
Ul Signature Title G/e„1c.'.'"y 4-s-�l.'4cJ
T=
(over)
DOH-1555 (02/2004)