Brown, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
w1 \ I ,o �a cl 6raw� M
Date of Death �JI Age If Veteran of U.S. Armed Forces,
G I
1 5} W or Dates ___
} Place of Death Hospital,
(CiOTo n9-er-Village C lens Ec t✓S ut,wet-AddI eSs 6 I e n S Fom S sp 1 i"c
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Manner of DeatINatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1❑Pending
l Circumstances Investigation
Ili Medical Certifier Name � h ,� Title p
Address 32.9- c(Wia-ko , P--f, warCL, N`'j- 12 8.W
ath Certificate Filed District Number Register Numberr^
City Qe G l s Foil 5(001 Li&ti
.['Burial Date ql ) I9- 12015 Crematory A,l_ \ 1e
['Entombment Address
,:Cremation Quxtrzr k_cl ,, D n51r_Ll- , 104- I Z O�
Date Place Removed
Z ri❑Removal and/or Held
2 and/or Address
I°= Hold
fa
Date Point of
Di❑Transportation Shipment
a: by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Ord, fuK14�-41t
Address i( LALr1411 l • ST <-t eoe it till- (?/ / -
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
it
ifs
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued `j I ( -7 (15 Registrar of Vital Statistics " "
(signatur
District Number 5 yr/ Place 6 CQJ\(\S .c), \S ' uJ y
.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 4111415 Place of Disposition 'Rd 016.1 C'rei4 s
(address)
LU
W.
CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises 1i,, 'l. 3 e vN
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iiiSignature Title �Q�M9K
(over)
DOH-1555 (02/2004)