Weller, Edward NEW YORK STATE DEPARTMENT OF HEALTH ' ` tie
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
L-6\ZO.C1 SSarnvkt\ U3e.\\er N\
Date of Death Age If Veteran of U.S.Armed Forces,
Q Z 101p1`4 g War or Dates W _
14 Place of Death , Hospital,tastttett oci or _ C
City, own or Village G\cnS fro\\ S Street Address gvS\'1 S'sree"'
. anner of Death Natural Cause Accident Homicide ❑Suicide E Undetermined El Pending
t Circumstances Investigation
ill Medical Certifier Name Title
n �Da,rc., - C-la;o-4 - GriAbbs 'N)
Address
\02 Parma S'rc&c-i- Gwnc F0\\c1 till • I2O
Death Certificate Filed District Number Register Number
City, Town or Village ?!'f
❑Burial Date Cemetery or Crematory
❑Entombment 03—) D t 1( )a01t • o-e_ �'_i W l n
_ e cnc*o(
Address
`< [ (Cremation aA± Ol\ry 1Z�Sd�
Date J I Place Removed
*In Removal and/or Held
- and/or
Address
Hold
til
0 Date Point of
ItU Q Ttri ransportation Shipment
5 by Common Destination
Carrier_'=s
;' El Date Cemetery Address
N.
, Date Cemetery Address
Q Reinterment
,
i:i --; Permit Issued to Registration Number
Name of Funeral Home �Inar c 1, taker Tuner aik,frk9— DI)3 0
RI Address LA
k L0.-t ..1 Q�1� S . , ccer t`f , 1V Q Yur 12 s3 CU
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
'` Permission is hereb granted to dispose of the human t�ttt\ains desc - ed ab a as indicate
<` Date Issued 4p/ Registcac of Vital Statistics n
(signature)
District Number 3 )/ Place /_.5 77J `
I cI certify that the remains of the decedent identified above were d- posed of in accordance with this permit on:
tit Date of Disposition /s,ly Place of Disposition Z24.4 a.uir,.-..
(address)
Ui
0
CC (section) i(lot number) (C. (grave number)
Name of Sexton or Pers n in Charge of remises !hr=i d J
•- "A.*
Z (ease PSI
. -- C7�4c't1 WIL
- Signature Title
(over)
DOH-1555 (02/2004)