Brown, Edward NEW YORK STATE DEPARTMENT OF HEALTH ` ` # I5-
Vital Records Section Burial - Transit Permit
7.2:ii: Name First Middle Last Sex
18
>ti>: Date of Death Age ! If Veteran of U.S. Armed Forces,
``` 3 l s-//4.- A/to ; or Dates /9.s7� --C3
e of Death Hospital stitution
own or Village c cam,.,s street Address cc,&.J s FeuS
v.. Manner of Death)Vj Natural Cause Accident Homicide Suicide Undetermined Pending
�t Circumstances Investigation
ft Medical Certifier Name Title
Po-1/4,,_ E14-ci in16,.) ,/(1,r) ;
4
- Address
/14/64 A..) /..j.ett4t,g)..J X'a dil-c ..ty
>< th Certificate Filed District Number / Register Number
"`1 City, Town or Village G'Ler,,.,f Fj E Fj6 0 ( Z I
Date Cemetery or remafoy�
❑Burial .3 /.S`//S I �i V U,4a-.7
Address �? /1 _ �1
Cremation 66� 12��; �1 �J iJC B Q2c, -✓ i / 2 e 0
Removal Date f Place Removed `/
1_i and/or Held
2 a and/or Address --
Hold
O o
Date int of
Q Transportation j Shipment
fl. by Common Destination
Carrier
:::::Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to f 1Registration Number
g Name of Funeral Home(I a yna rd u, 'Baker /"u-ne(cl/ Home.. Of i '0
• Address 1
.. /I Lcc LyEt c j . C.qLcnsb�,Lr9 /Uew 1 r)L / '1
r
:;z. Name of Funeral Firm Making Disposition or to Whom
TZ Remains are Shipped, If Other than Above
Address
IX
RI
Permission is hereby granted to dispose of the human remains described above as indicated.
11 Date Issued 31. / t,5 Registrar of Vital Statistics W Gn_AiY ��~"
11,
(signature)
= £
kit District Number Jr' 60 I Place 6 UArN,s Fa\\,S , N'"
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition 3i') I;- Place of Disposition ivi,k, C „—,
w (address)
>A
IC (section) (I%number) r (grave number)
ci
Name of Sexton or Person in Charg of Premises 4, t,,41--
,/ (please print)
t! Signature (�L ///j ../.�..,,- Title .'f1, oft
(over)
DOH-1555 (9/98)