Garnsey, Orson T _on.. 1 y
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
e Name First^ >fiddle Last Sex
-...,
_:=
Date of Death .- Age If Veteran of U.S. Armed Forces
= ® \ ( 0 y, 19-0l S War or Dates
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Place of Death Hospital. Institution or
City,Town or Village (i_E I•s 3 r A u-3 . Street Address CD L.E- N S F to Ls.- tic' 'e I T/S
Manner of Death Natural Cause 0Accident Homicide Suicide
Name Undetermined Pending
Circumstances Investiga1tion
Medical Certifier
fiat-1s C L. \.J NA
Title �
y Address
l k oe pA s.c.. 7.s7 ( L... tJ 5 C A LA -S i )LA. 1'- $$O
Death Certificate Filed District Number Register Number
_:. City,Town or Village ('t-C 5 V A LDS S�0 c U 7
Date l metery or Crematory
-:= ❑Burial O 6 ! � v w_ L U i- t%t J C. q_a M 6.TG L'"l
tt'�c tl Address
L^l Cremation C A tLE.:Q___. QZ' LL- ti k -Az`- t `-t \ �$O'f
Date Place Removed
0 LJ Removal and/or Held
N and/or Address
F., Hold
5 f Date - ?Lint of
Transportation ( _ _ j Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
,:: 0 Reinterment Date Cemetery Address
`<a<> Permit Issued to } Registration Number
5 Name of Funeral Home Maynard 1 Baker Fu.nercl Home- I of C
". Address i i £ v ate (3f. , O Lte.C.nsicu ;Alai)) iIUr1t- /Q 2?J`l
'Sti Name of Funeral Firm Making Disposition or to Whom
` Remains are Shipped, If Other than Above
Address
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'" Permission is hereby granted to dispose of the human remains described above as indicated.
Oi Date Issued 1 1 j, 115 Registrar of Vital Statistics W c e.
010. (signature)
:: 6�. \�>> District Number S ( Place S S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
toDate of Disposition i/7!1 ` Place of Disposition ,? IL Lr .r'-._
5 (address)
144
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Cr (section) it number) (grave number)
GName of Sexton or Person in Charge of Premises 4(.... 4
£U �JA (please print)
Signature / -✓ Title Cac Wihata
(over)
DOH-1555 (9/98)
1