Eno, William r e r
NEW YORK STATE DEPARTMENT OF HEALTH A f/3
Vital Records Section Burial - Transit Permit
Na�i 1F�r�t0�.1'1'1 � Middle ��� Last Sex /�
In
Date of Death Age If Veteran of U.S. Armed Forces,
liii (5' Z) - I S -7 9 War or Dates / Jo
: Place of Death Hospital, Institution or
(City>Town or Village; a CL Sp r i► v Street Address L a� I f a I
ILI Manner of Death • Natural Ca e Accident Homicide Suicide U.Idetermin Pending
LU Circumstances Investigation
ILI Medical CertifierName x/ Title
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Addres
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pf P h Certificate Filed �1 Dis ict N mber Register Number
Cites own or Village s C�j r) 150 I 'Z-( 7
Date J 1 C etery or Cremato
❑Burial / ---,Z
-7 � + I ( _
DEntombment Cp ` Z 0 15 Nine V 1 e �C,Ma fry
Address J
Cremation GlAtulthikrui (\i �
Date J Place F{emoved
Z Removal and/or Held
C ❑and/or
I; Address
to
0 Date Point of
Di❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 0-ex- vex ( Ho r, Inc. 008- 1
Address
- Uf-C.N St La_1(Q. L z-t 18 4-(o
ilili Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
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:i:(` Permission is h re y granted to dispose of the human remai cri ed air indicat .
Date Issued I I S Registrar of Vital Statistics
(signature)
District Number SbI Place 5)cr.i.A.4,74..Ac..4 11,1/!
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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iti Date of Disposition �i41TT Place of Disposition itt., cad._
2 (address)
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to
cr (section) /, (lot number) (grave number)
ci Name of Sexton or Person in Charge f Premises rsiv
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Signature Title ar,ovie-
(over)
DOH-1555 (02/2004)