Dally, Arthur f . f /77
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
tkQTNv V- RAtirn0L7 `JAL.'.-`t n
Date of Death Age If Veteran of U.S.Armed Forces,
eO3 I oc I as LC 3 War or Dates 1� La- `.R Li.c
1.4 Place of Death -, Hospital, Institution or
City, Town or Village CDl.-CAS tc S Street Address (7 LJ Q_S cT(L..`-S cP i
Manner of Death jT ElNatural Cause Accident Li Homicide Suicide Undetermined Pending
ILI `'� Circumstances Investigation
ja Medical Certifier Name Title
csi bc..N,s( 1_-� ,_1;scs 0
Address
100 ?tee S T GL_E►.) -C -5 N -k l a-V-)1
Death Certificate Filed District Number Register Number
'A City, Town or Village C LC;t� P L1_S S L� ! 3
ti
It OBurial Date m eetery or Cremator
6 � ' 1l Iao9S X\ t: U.\ew C YC-1.c`-‘ wTaiz `.1
❑Entombment Address
r= Cremation ( �,A�i=.(Z R-oia7 Q.-,t' L-=NSC30%Lc- (---- 1aQo`�
Date Place Removed
Removal and/or Held
and/or Address
tab Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiiiiPermit Issued to Registration Number
NI Name of Funeral Home 140,v/fu 8 !�, P&aker Funer c_i mR- (.� 1 1
Address
I1 La c yQ-He- S. , au..eensbL ( 1 , tiev.1 `/ork_ 12's?Oy
NI Name of Funeral Firm Making Disposition or to Whom
1'`: Remains are Shipped, If Other than Above
Address
t. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3`/0 / )_j Registrar of Vital Statistics W0A.A., 12
r (
/ (srgn atu )
ipi District Number 5 6 0 ( Place 6 (.Q�S Fc �1 S W /
<. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ,3/z I►c Place of Disposition 1,w Croral
(address)
(section) ' ..(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises 6 ro" 5/,,,,A-
Z ,(please print)
ili Signature A Title OvE411 ii
(over)
DOH-1555 (02/2004)