Dixon, William . > 714(c'
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
± Na a First Middle Last Sex
'I (I la Irn C N Ac)n Pil )e--
iiiiiii D to of Death Age If Veteran of U.S. Armed Forces,
>; LI 1Z. Z(_) 1e3 76, War or Dates lc/ (o _ 1(H(0T
Place of. Bath \' Hospital, Institution or
City,(ow or Village Street Address a 50 , 'S1 RC
j.Manner of Death"�Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W `'"� Circumstances Investigation
Medical Certifier Name Title
IP MIc aH.I lI kih
Address
"uc, n -6(1 r: L i (eA156 )(r. Ny
iii Death Certificate File District Number �J Register Number
City, o or Village I, 5E
Date y Cemetery�o/r Crematèernitfvj
y
CI Burial C1ILI -Z015 P, ne. V1Lu) '
Ass
:::: N Cremation U L115 bu r
Date J / Place Removed
2 Removal and/or Held
Q and/or Address
Hold
Q Date Point of
ai Q Transportation Shipment
a by Common Destination
Carrier
i : LiDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
•i'' Permit Issued to Registration Number
EaName of Funeral Home :t liv i-al -1--ionv�
'<� Address
. C`kill rc�h 3t Lc .u Lu
�- /Z get6
o Name of Funeral Firm Making Disposition or to Whom
•r' Remains are Shipped, If Other than Above
E Address
ix
• a
iPermission is hereby granted to dispose of the human mains desc i d above as indicated.
.< Date Issued -1 -1 y-15 Registrar of Vital Statistic S73! C'\C\( \ti�
(Si Lure)
District Number Place \ C1\9.' \ c 1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f �
6 Date of Disposition °)1161(S' Place of Disposition `' �f IL (w► cr*%w_ •
2 (address)
Lij
CC (section) Alot numb) (grave number)
G Name of Sexton or Person in Charge of Premises • - t.r tsllzt-
(please print)
W Signature Title (i jTt
(over)
DOH-1555 (9/98)