Turner, Dennis NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit SIt Permit
Vital Records Section
Name First Middle Last Sex ,A\
DE.V1(11 S 9v1J-t-��t- i uY- 14 e-
-i Date of Death Age l If Veteran of U.S.Armed Forces,
0:
b I I " I`�1 tt Q 3 War or Dates N 14
Place • •-ath Hospital, Institution or
Ci Town , Village A • Li Street Address FIT_ •. \y i ' Wit
Manner of Deathi4Natural Cause D Accident 0 Homicide 0 Suicide
Undetermined 0 Pending
61 Circumstances Investigation
Medical Certifier Name Title
3; Address
14 tISct S . .-AR G rIto .cln 1zS3Y.
Death Certificate Filed District Number 1 Register Number
- . City,Town or Villa9e v .�
Date `� I Cemetery or rematory Q<Burial CA 14 i ZC�1 `4 f t r i�-. Vi C w esrp r t`-Li-
Address
�4 Cremation
Date Place Removed
a
:;❑Removal and/or Held
and/or Address
r Hold
d Date Point of
.` ❑Transportation Shipment
a- by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
'` Permit Issued to Registration Number
Name of Funeral Home HC- and b, maker Funeral home. *1 f 3o
"--#''''N Address // La:r ydtte 3+. , &Guawsbur9 iitie,w i'JOr l geUq
Al Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
iti
Ro Date Issued 110//y Registrar of Vital Statistics t bUC//t�...�
01 (signature
District Number 51 sU Place &rryLt
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. Date of Disposition 11)9 1/1Place of Disposition Z L1L rq p{,_,
(address)
(section) clot tuber) (grave number)
o- Name of Sexton or Person in Charge of P emises ..► r 3Diw. '
i 41—
(please pnnt)..' Signature Title GK lit fiIN',
(over)
DOH-1555 (9/98)