Daggett, Robert NEW YORK STATE DEPARTMENT OF HEALTH�� �` [SI
Vital Records Section Burial - Transit Permit
Nro F, first . Middle �ac SAIa
/t'
Date of Death Age If Veteran of U.B. Armed Forces,
?—95 A ,U)/5_ 89 War or Dates (jt.)(,031.
I- Place of Death Hospital, Institute nor /1
W City, Town or(JIla -dQ.rCtj)a , kft.,ke, Street Address i ron<ta c L Mc ica I Gar- .
W Manner of Death Natural Cause 0 Accident Homicide 0 Suicide ❑ Undetermined Pending
Circumstances Investigation
W Medical Certifier- Name Title
a K Dvut,Id ge00 e._ COrrnew
Address U
Death Certificate Filed District Number 1 isC.03 Register,Number
City, Town o(Villag4,SCL,rct,i&c—
❑Burial Date C etery'�p�r Crem tory
1 ��5' ' inx. V1CI, ) £i'€i701v ry
❑Entombment Addees
®,Cremation U cL/l6bw-11 1V
Date ! PPla6e Removed
Removal and/or Held
and/or Address
Cl) Hold
0 Date Point of
Di 0 Transportation Shipment
a by Common Destination
Carrier
QDisinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home A'1 t Her 1 n e I -jorx 01199
Address ` 3 5 7 S-k - ►2-IL 30 /nU La_i 1 L_L _ 1K. M// /12 Z'
Name of Funeral Firm Making Disposition or to Whom i
I-- Remains are Shipped, If Other than Above
rc► Address
tr
41.1
L1 Permission is hereby gr nted to dispose of the human remains describe above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number WE,
3 Place Village of Saranac La e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition 3) S Place of Disposition ,,,t(L v
W (address)
Cl)
IX (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 61 . -5e -
Z (please print)
Signature Z4_,.., Title 117 i14
(over)
DOH-1555 (02/2004)