Dow Sr, Walter ci
NEW YORK STATE DEPARTMENT OF HEALI H 'it Tl so
Vital Records Section Burial - Transit P rmit
Name FiriO Middle
wftL l'( ast
.Le)(A) J , $e v
D to of a th Age If Veteran of U.S. Armed Forceps,
"�`� 15 Y War or Dates Tia.S
PI e of Death Hospital, Institution or
„s own or Village (L f' QyJ' Street Address
ner of Death TrNatural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
LIE Circumstances Investigation
La Medical Certifier Name A 1 a TitleA,,
Addresth
to a r Cam- CIF/ u / I /
D Certificate Filed /s J"'' / District Number cj L® ' Register Nu ber
own or Village ( /?•% r.�d- V 53
is❑Burial Date Cem�e • Cr- .to.
l)-Dot-� l -i - . o c. wmpix-v
0 Eyrnbment Address V.
giiiii remation a v i rK�-_ P . 1 I, t
Date Place Removed
iS❑Removal and/or Held
and/or Address
r.1 Hold
U)
0 Date Point of
ti❑Transportation Shipment
Et by Common Destination
siii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Ntgnber
Name of Funeral Home I 4"4A-1'- frt L iM .- fVJ F( t_ )4O144 E 0 told'
AddrHI ss
� , IM, / , S).. 30 . , i* �,.. N I/ 1-2_,--ci
iiii Name of Funeral Firm Makin Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
Ifs
tu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /t-act-�rods Registrar of Vital Statistics LA.310_U .Q. UAACI-
(signature)
District Number 5.6 Q ) Place 6 (s2nA.5 k s, I"'y
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
ta Date of Disposition ii/i/t5- Place of Disposition ,, ,-, (nt•..y640„-
(address)
la
Cl,
' (section) n (lot number) (grave number)
Name of Sexton or Person in Char a of Premises ra`",�
�,�
�. (pl"ase print)
1thruovt
Signature A Title
(over)
DOH-1555 (02/2004)