Carroll, Christopher NEW YORK STATE DEPARTMENT OF HEALTH Y , ft 631
Vital Records Section Burial - Transit Permit
Name First r; , n 5p Middle na Last afro i' Sex
gii> Date of Death 1�I�IJ Age n i_ j If Veteran of U.S. Armed Forces, —
War or Dates
Place . m eath Hos stitution or
Ci Town r Village ( e�- , treet Address Zg� U: O
:-� Manner of Deatty( Natural Cause Accident ❑Homicide 0 Suicide Undetermined Pending
ilU iJJ�� Circumstances Investigation
Pi Medical Certifier Name D^ _'lc 1 \/ ' - Title C o(o��
gi
�� Address M - -
�-IO c�l l I S�`er, S+ . tatty-) S /i
/ . 12 D20
i Deat ificate Filed i District Num r 1 Register umber
mi City, Town r Village ��Or'�C �. i (j I 35
Date I I Cemetery o�rematoiy� A. ❑Burial Z Z 013 I at_ VI eA.>.._,
Address
:::.cremation Q 0.k.L-: R_ ..) ( uts_ra �b i )1 1 Z 3 o`-1
Date -' Place Removed
g El Removal 1 and/or Held
and/or ------
Ei.; Address
- Hold
Date -- --- �u nt of
0 Q Transportation i { Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;.i Permit Issued to { Registration Number
` f Address l Name of Funeral Home & A r F2triera../ flume__ f 01 i 0
id 11 Larc - -te 3+. , Occe..ens&try ; /Uew L%Tk la8Oy
': ' Name of Funeral Firm Making Disposition or to Whom
44
Remains are Shipped, If Other than Above
Address
M •
Permission is hereby granted to dispose of the human remains described above as indicated.
<. Date Issued 7/9/l/5.. 4L1'12,'93A..Registrar of Vita! Statistics 41��-tA-c---
§ (signature)
11 District Number y56'A Place Thi✓ll e r /12C//C.L a 4-L,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition 7/11IiS Place of Disposition 47..U.,r `a4,7(O,N...
W (address)
Ce (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises ��'1`"number),
(please print) /`_
I. Signature (%� Title ateisfrnit
(over)
DOH-1555 (9/98)