Wells, Edwin NEW YORK STATE DEPARTMENT OF HEALTHl1b
Vital Records Section 4 a Burial - Transit Permit
Name First �1(� , Middle �� �st Sex /
Date of Death ,, _ Age If Veteran of .b rmed Forces,
s�s7/,` 72-- War or Dates a ,
Place of Death Hospital, Institution or
ifi C y, Town or VilOge Gam//% Street Address LI �j/Jld/� j/of f
0 Manner of Death Natural Cause 0 Accident El Homicide El Suicide ❑ ndetermined ❑ ending
V111
Circumstances Investigation
ill Medical Certifier Name Title
gas/y/7 iz /0 ',d.
Address
k.S/M /Mf 5/21rr2f4 /% ,le�A5h /9 /ll/ 26 z/
Death Certificate Filed istrickpumber Register?! mber
City, Town or Village 91,f
El Burial Date Cemetery or Crematory,`
['Entombment Address
P/ v i< i iii7 T/
Address
`:.tR'Cremation 4)agriStiliY itY
Date Place Removed
❑Removal and/or Held
' and/or Address
Ilt Hold
V? Date Point of
85 0 Transportation Shipment
25 by Common Destination
Carrier
Mi
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to �� ��� //�� / j� ,�/ Registration/ Number
Name of Funeral Home Jj7 / / 74! '!fin[ 231U V.
Address " �"/ u4 J 2 c� re�Ujiiiiill Name of Funeral Firm Mafa
g Disposition or to Whom ✓ 1 //
Remains are Shipped, If Other than Above
Address
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tt
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ,574 /L/ Registrar of Vital Statistics
(sig�
District Number Place b/2/9 ,2/ 2j/ #
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k '�
iI '�'+�
Date of Disposition s�i1'ly Place of Disposition t it
X (address)
UI
1r (section) 1 (lot numberh (grave number)
0
13 Name of Sexton or Perso in Charge of remises /Alia., JCn^1N
ase print)
10
Si nature Title ( lfrott(
g .
(over)
DOH-1555 (02/2004)