Alden, Howard NEW YORK STATE DEPARTMENT OF HEALTH, ) 0 511
Vital Records Section Burial - Transit Permit
pi Name First ;' iddle t Sex
I/O tJ O- 4, (3� tfAJ /1 82 b)
<' Date of Deat Age I If Veteran of U.S. Armed Forces, \
{C`3 3 pZ ; War or Dates yj � et,1i,,� . 7 '
Place of D ath I Hos `i Institution(or
i , Town or Village ,�0 /'pj t,0 Street Address L ,,),3
:.: anner of Death Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined Pending
ill Circumstances Investigation
IliMedical Certifier Name Title
0. T1lnoma�Name -�-t��e.. A eiNOi Phys►ctan
▪�� Address
F t< 1 o® excaeL Si'. , 61_0-&,o VeLi.Lo J 12'4 01
»°' D ath Certificate Filed District Number 5 >0' 1 Register Number
` C own or Village u-Ge-„l S FF u I �� D 1 3 Li 6
Date l I Cemetery Crematory 1 i
El Burial 7 //i/ r /..) is V i bk)
�1l_ Address
cremation L. Lc >,j n J f3'c�• (S LN '
IL
Date and/or Place Removed
g Removal
and/or (-Held -
_ - -------- --- --- ------- -
ns Address
> Hold
0 Date __ -- vine of
NTransportation j Shipment
a by Common Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to L Registration Number
mi Name of Funeral Home Z ' Funcccca //oMc, at i �(�
<> Address ,
ii tarat ,-ttc of. , 0Lteens&Lai , jueLo Ljv-lc- l,2eo
>> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Iti
3i
>= Permission is hereby granted to dispose of the human remains described above as indicated.
iig Date Issued 71 '4-1 /(5 Registrar of Vital Statistics t../\i ,,e y ,
(signature)
'> District Number 60 i Place 6 U./v..; f-,,,, 1\ s tv y
I certify that the remains of the decedent identified above were disposed of in accordance withth this permit on:
e (,r° Or
Date of Disposition ll(;1/'� Place of Disposition ..� �, ,,�.,,
2 (address)
iLl
th
IC (section) (lot number) (grave number)
dName of Sexton or Person in Charge of Premises �f,, S' „04.11-
Z (please print)
4! Signature ���' Title (4.A4/04
(over)
DOH-1555 (9/98)