Bailey, Carl NEW YORK STA.. EPARTMENT OF HEALTH 7 f i
Vital Records S'eicai Burial - Transit Permit
Name Firs "_. Middle Last Sex
LArLL- / Vl is-CiA. 3A1 V 1tl
_... [ Date of Death Age If Veteran of U.S. Armed Forces,
2-?-ii-24) I C &0 War or Dates
,—
ii4, Place of Death n ��_ Hospital, Institution or 7,-ZZ 3 U E fist,o,u r V,& biz-
City own Village COI---0 #i 1 E Street Address lot Gty,..o1v i 0.j i12i S 1
Manner of Death Natural Cause Accident �Homicideuicide Undetermined Pending
3J! Circumstances Investigation
tu Medical Certifier Nam Title
b CDet. Ceiz„,
Address Z S-6, -e Jk 0
Death -a"ficate Filed District Number 95� Register Number
City, Town ,r Village ,--0 pi E c27/
ii:i:::0 0Burial Date Cepytery or Grpmato
L2 -Z4-740tS 1jE V) Vl �� 1A-TN-V
< :.❑Entombment Address< >: emation 1'✓1t I'��"✓IL 1�j a 3-6,„_4� ` ' 1
� , ?.-tFV li
Date ' Place Removed
" �Removal and/or Held
aHoldnd/or Address
In
O Date Point of
Transportation Shipment
is by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iailEl Reinterment Date Cemetery Address
il Permit Issued to J Registration Number
Name of Funeral Home Oj 1�1t --iv►.'Fir� XJF .1"'�OWt e o I d'
f> Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 42-4'/5 Registrar of Vital Statistics �''�, CeL- -v
iiini (signature)
District Number /56 Place97--0-7477( ref-kk ?.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
try Date of Disposition 12-1-1-15 Place of Disposition ) ha vre.j 6rem
a (address) i
Si
ii (section) (lot number) (grave number)
0
L1 Name of Sexton or -erson in Charge of Premises i k /.4.ri (L-044-c-€-
2 - (please print)
SignatureW. //r/ � ° Title -�m 4-4a-/
(over)
DOH-1555 (02/2004)