Burt, Stephen NEW YORK STATE DEPARTMENT OF HEALTH 7.1 $3-)
vital Records Section . Burial - Transit Permit
Name First Iddle
Ag..". 3LLSex
Date of Death `'t.P /11,�,L{
Age If Veteran of U,S. Armed Forces,
It /'�S aoir (ram War or Dates
Place of De Hospital, Institution or
City. Town Villa or;A 1. Street Address
H
0 Manner of Death Natural Cause 0 Accident Homicide Suicide �
Z /x
Undetermined — Pending
Medical Certifier Name • Circumstances Investigation ,
CI Title
c.k"c.L S;, 1;-r;c MO
Hddress
-Ctf Death Ce irate Filed ri, 7f awri S rit S , r Ia�&
District Number v Register Number
City. o or illage �jj r• y-S SS ,
Date Cemetery or atory
Burial 1177 ll S'� _ ,t
Address Y•c.� C,. .
ji Cremation ��<.t� ..r 4 `'
SS ,0 "
Z • Removal Date Place Removed
O —' and/or and/or Held
Hold Address
0 Date Point of
v Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Date •
Reinterment Cemetery Address
Permit Issued to
Name of Funeral Home �-, RegistraliorLNumber .
Address ... .„1 ,,rr �A n tr,( i-bgt, l.c_ poy-�C�
Name of Funeral Firm Making Disposition or to Whom
~ Remains are Shipped, If Other than Above
Address
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la.
Permission Is hereby granted to dispose of the human r: • •:scribed ov: . - •boated.
Date Issued It/'27 fly R4istrar of Vital Statistics
NI�-,a •re)
District Number L/` Place P, , •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- p� �I
' w Date of Disposition 413,11r Place of Disposition Z.L rel4rr..
(address)
w
v7
(section) I numbe
Name of Sexton or Person in Charge of Premises ( l =L �) �t (grave number)
Z /� 4_,
(please print) /" �l
iAtirg
Signature
(sue Title l
DOri•1555 (10/89) p. 1 of 2
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