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Fuller, Elliot NEW YORK STATE DEPARTMENT OF HEALTH,. , N T ti 143/ , Vital Records Section Burial - Transit Permit Name First -' ` \ Mi dle Last Sex ► G trcnea S 1 L, Iler Date of Death Age If Veteran of U.S. Armed Forces, Lo \ t } 15 4-(o War or Dates Place of leath Hospital, Institution or 1� ^ City own or Village r�, Street Address (,�aSl,;E\. �� IC-�\ 2 Man - of Death%Natural Cau'�e 0 Accident 0 Homicide Suicide Undetermined �Pending Circumstances Investigation tg Medical Certifier Name MQ Title f-A0 Address ` Cgr . , �-t � �� , 1je1'� 5fi�s2st� r�1Z Its li Death Certificate Filed District Number Register Number City, Town or Village r<°[ OBurial Date / \ l 1 I Cemetery or Crematory ❑Entombment Address ) giOc ' remation Dw).�1C.P C Ce S✓�--�,r `y Date Place Removed ° l v Removal and/or Held and/or Address i Hold f 0 Date Point of ii 0 Transportation Shipment a by Common Destination Carrier Wi Q Disinterment Date Cemetery Address p.iQ Reinterment Date Cemetery Address Permit Issued to m Registration Number_ iMi Name of Funeral Home I ' I ci �rn ec }-`, Dome- 0 1 © '3- >I Address ),30' M eq i n S - (2,21- 3ouAm Cis r� 1 15 Nj I ?3O3 pii Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address la Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued (,-/U-,)0/5 Registrar of Vital Statistics / kik " IC)► f16,..-4-1429.../---- (signatgii ure) ) District Number 5-7 soPlace �Gwx1 c ar-ciclb I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tLI Date of Disposition G-0 -is Place of Disposition ?`nQ U i'et.,) Cr,ew,c vr,',,°,,,-, III (address) CC (section (lot number) (grave number) 1 Name of Sexton or Person in Charge of Premises t w1 04.1i. 2 fo i-,e((e '" _ (please print) Signature �titi .u1 Title Craw,c voix' - A45S`4 . (over) DOH-1555 (02/2004)