Charlton, Willaim It
NEW YORK STATE DEPARTMENT OF HEALTH I t J(O
Vital Records Section Burial - Transit Permit
» Name First i Middle Last Sex
j,\\,G ey. �b5tV1-i Lt:AAZI--To1.i OA
': Date of Death Age If Veteran of U.S. Armed Forces,
lin 31 S I -O 15 5'" War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village CAr G N S CABS Street Address (,L Era s i�4r-L-s �,5\>►i P 1---
laManner of Death Undetermined Pending
Circumstances Investigation
fa
in Medical Certifier Name Title
tq.i C iiA .t_. A' ,A r•1 S 'M `7
Address n ( ` t�
C�� � „�� aTN V�I.N� FALL nAL15 1V1� ' �`C� O
Death Certificate Filed District Number Register Number
City,Town or Village l7,L L N `. lAz s 5 (p O 1 f?-97
>>`❑Burial Date h, /�i S Cemete or Crematory
❑Entombment l V in \-e`"`' �c , c o�'i
Address
( ,Cremation I�CvALt c A> �.7 Q� G 1_,5 ,D2 I � ‘ a-��LA
Date Place Removed
❑Removal . and/or Held
and/or Address
+
Hold
0 Date Point of
05 Q Transportation Shipment -
a by Common Destination
Carrier
%Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
gili Permit Issued to Registration Number
Name of Funeral Home M/1ti (J A2 i* 7 V Pic o \ ( -O
Address
11 LA rAti r-r E ST (svcc- tsauz,-.. ) N.1,, PVU`-f
il Name of Funeral Firm Making Disposition or to Whom
li Remains are Shipped, If Other than Above
E Address
l
iii
Permission is hereby granted to dispose of the human remains de . ed ab e icated.
g< Date Issued (�3`O6/20/ Registrar of Vital Statistics � • i,, .
(signature)
0 District Number d)/ Place .-e,t,t.0 ,c /f N y
$-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
iti Date of Disposition 31'ij is- Place of Disposition u0M0 eµ 1
(address)
tii
(section) (l number) (grave number)
ri Name of Sexton or Person in Charge of Premises • \ AA/4-
(pieasel
Signature h /r' Title C �� �
(over)
DOH-1555 (02/2004)