Verry, Elmer 14
NEW YORK STATE DEPARTMENT OF HEALTH 4 t30
Vital Records Section Burial - Transit Permit
r<%' Name First Middle Last Vac
r 1 Sex
li
Date of Death 1 Age If Veteran of U.S. Armed Forces,
01 t O old War or Dates \CO Z—1qy.
`7"- - .ce of Death Hospital, Institution or
70,1lown or Village G\ens �a\\S ' S,LsiAddre 1\' U,P,Qey '()\ok-\-\- e€4-
Manner of Death Natural Cause Q Accident I I Homicide 0 Suicide 0Undetermined El Pending
11.1 Circumstances lnvestigation4
gMedico(Certifier Name Title
ci LDN.cti\ Med fbr) PA\-effV.1.14____ i\lyickvy
Address
a Death Certificate Filed ' District Number r Ol ), i Regis u per
`' '�ity�Town or Village GUn vc \\S t 1 l Y C
T Date I Cemetery or Crematory
❑Burial 1 Cam} 0-1 I ZON`-k- A`(lt_ \]iQ __C4 Qaa (y
Address
7Crematlon
r Date Plac� Removed
O f-"Removal i, and/or Heim
and/or
Address
Hold
s Date ?::rnt of
624 fl Transportation Shipment I
, by Common I Destination
Carrier
Disinterment Date i Cemetery Address
Date Cemetery Address
C Reinterment
Permit Issued to Registration Number
Name of Funeral Home /Cf- i)C2rcl 6 cXe' FuilNial 1 acne CI ) l Address ___ _ -1
fI LCif Cc_i/L-tic . , Q� nSi a14-:� , 1UeW �ivrlL l �O4f -
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address {{
bA
Permission is hereby granted to dispose of the human remains described - •ove as i •icate-.
Date Issued Q'7471 /l` Registrar of Vital Statistics A(s •n,. ure)
District Numberj/ Place _ _
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
ff''
Z, Date of Disposition 1-q 01 Place of Disposition 4741),... 64.-/ 4,---
(address)
w
N (section) t number) (grave number)
2 Name of Sexton or Person n Charge of Premises - Sn4t
2 (please print)
' Signature d/ 1(-- --- — Title C11164/11lit
ioven
DOH 1555 (9/98)