Craige, Saunders -t-
NEW YORK STATE DEPARTMENT OF HEALTH SS5
Vita( Records Section Burial - Transit Permit
kflii Name First Middle I Se
6�,., S -7-- ► -1 IC I It9Z17
v? Date of Death / ' A ? If Veteran of U.S. Armed ?ices, _
2/2'5J i ? A - •r Dates t-J ,lam
" - -. e of Death �i I osprtal nstitution
"'��City, own or Village `-1 g%rv> F�-i- j ! Street Address LiG/,/ _3 FIJ
°� -nner of Death ELNatural Cause fl Accident n Homicide Li Suicide n Undetermined El Pending
Circumstances Investigation
Medical Certifier Name AQ d rne_dTitle ca, L
tjctetti
(f �/�J//Address
aeln.5 -iC(\\,S A___ ICt.\
. ; h Certificate Filed,,, District Nu b I Register u r
=F City, own or Village (..,&r„.)S - u S
t
Date i Cemetery or rematory
::: E Burial 7/Z7 I� , ..t �/�
Address /
::' remation UILa_ ___ j c.) G'i3 CS z1
Z Date i Place Removed / /
0❑Removal
and/or I and/or !eid
CO
Hold Address ------
0 Date - -?;int of ---
C Transportation i
{ Shipment
n by Common Destination Carrier
Disinterment Date Cemetery Address
❑Reinterment Date : Cemetery Address
Permit Issued to
Name of Funeral Home -Backer Ft-w .ICt/ 1/Om 1 Registration Number
': Address r 0I1 �U
lI Lcc{a y �� fit. , 0 ULCZnSbUrCd ; /UeLv /Uf)(- /c2e01
lq Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;" Address
Permission is hereby granted to dispose of the human remains described abo'e as indicated.
`= Date Issued -7/ZS ) i 5 Registrar of Vital Statistics AN QA R,
(signature)
District Number 5 Place 6 ins rci, (1$ ) 4 v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
it
F Date of Disposition 7-as-I S Place of Disposition l rr1P cJ.`es, Cfemafr brCi/wt
ill
(address)
03
tr
sectio ) (lot number) (grave number)
g Name of Sexton or rson in Char of Premises I c wv,et It,' u 2r ,,14/(
4 j L (Please
Signature Title
C('>°hcfer4 I��'
_____________i
(over)
DOH-1555 (9/98)