Stiles, Raymond ` ` 4 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit ermit
Name First 2 Middle Last Sex
I \" /hL),l (A /71 • ,s-fi- ir__5 pi tile_
Date of Death Age if Veteran of U.S. Armed Forces,
9/1a. a 0t1 sy War or Dates
Qri)vf Death rHospital, Institution ori /y, n or Village 6�.,Y - ji S Street Address ‘b4 1:::11r 14'�ip
ner of Death 0 Natural Cause C Accident 0 Homicide ❑Suicide ❑Undetermined, 0 Pending
LtiCircumstances Investigation
W Medical Certifier Name Title
CI �C.a•• i,� Al IJ
Address
i bo AtK St G ,5 +title- Ni / $a (
gii De Certificate Filed
ty J�, wn or Village qL„5--J-,( ,— ' 56 0 / .
Burial Date Ce tery or Cremat 1
['EntombmentJ/lS-//1 /le✓;,,w re..--i--t.r .
Address
Cremation // Y .
� C'v.S LjJf
Date r 1/ Place Removed
isRemoval and/or Held
;❑and/or Address
E=~ Hold
ta
0 Date Point of
Li
❑Transportation Shipment .
G by Common Destination
ei Carrier
liiEl Disinterment Date • Cemetery Address
a❑Reinterment Date • Cemetery Address
Permit Issued to Registration Number
>< Name of Funeral Ho /�„S+ o rc 7 ff lc_ • o 6�-'7
miq Address c--_
Name of Funeral Firm MakingDisposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ILL
Permission is hereby granted to dispose of the human remains described above as indicated.
' Date Issued 9/1,5 f!'� Registrar of Vital Statistics L1 0..A'p--* (sia_/(signature) `�
District Number 5 bo i Place G S vo.\\s I l u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tLi Date of Disposition 11 njII Place of Disposition Pit-, Crrn. ...
W (address)
til
Cr (section) i (lot numb. (grave number)
0.
ri Name of Sexton or Person in arge of Premises `G�r.* i%elf
dlease print)
t Signature Title c*
(over)
DOH-1555 (02/2004) '