Green, Jr. William NEW YORK STATE DEPARTMENT OF HEALTH .1.
Vital Records Section Burial - Transit Permit
I::-,::;:' Name First Middle Last Sex
Date/of Death Ageo-,7, , Veteran of U.S. Armed Forces,
o-c i a , _ p u, , : War or Dates A j 0
Place of Death ' Hospital, institutiA--n or ,-
-,,A City(fswL>1 Village c,LA..d. ; Street Address Co e..2...t
-- / lejLe 10
-3. Manner of Death i_jr-1 Natural Cause 0 Accident El Homicide In Suicide 0 Undetermined El Pending '
„,__ _ ---_ Circumstances Investigation,
Medical Certifier Nime Title
a
Address , —
..:. ,-.
,.:.' Death Certificate Filed . i Distric*NuTher : Registgc-Number
'-:::.) City.(C5vTiO1 or Village e',..QA__ _A jj 1--S-- 5
......., Date
LJ 07L/e,z Ce tery or rematory
Burial I
Addr
. 0 Cremation i
n
Date PI e Removed
I rn
Removal and/or Held
. and/or -
Address ' '----- --
= Hold
6 -- ,_. ,
, Date
Point of
Transportation , Shipment
— .
5, by Common Destination
Carrier
Date Cemetery Address
• El Disinterment
. - -
Reinterment Date
: Cemetery Address
El
- Permit Issued to Registration Number
I.. Name of Funeral Home )-U-L) \ ----4 -1---L---,- -Ag---- 0 0( .-- } )
,..
Address
af\1A-- ,C-A . .&€ _
- Name of Funeral Firm Making Disposition or to Whom
ii•'•
.0. Remains are Shipped, If Other than Above
----
Address
---'
Permission is hereby granted to dispose of the hum emai s descred ab.,to, ,- indicated.
Date Issued d7---k- 20/2- Registrar of Vital Statist' ,o,42.e___ L.ir•
-.:
-. ( nature)
District Number
Place 4 0 On
- ' ' - '..1--,
'. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f.r
Z Date of Disposition 7-30-12 Place of Disposition PI!ne U:f(.,) C..lNefrytc,:tort.0 viri
bi
2 (address)
tti
0
te (section) (lot number) (grave number)
01 Name of Sexton or Person in Charge f Premises —i-Tyvtokky gir`vil.-tiC
0
2 (please print)
LU Signature 1.„. 1 -,4 Title C-f-x,,c3 c.".1 455 4-•
DOH-1555 (10/89) p. 1 of 2 VS-61