Spellburg Jr, Earl NEW YORK STATE DEPARTMENT OF HEALTH 5s;
Vital Records Section '' Burial - Transit Permit
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II Name First Middle Last I S
><r 3 v iiZ L �0 S 0eib �`'CC,2o a S, (Ti
Date of Deth / I Age ! If Veteran of U.S. Armed Force
S'i3 a/l y ! ..f 6. • War or Dates Ai )8'
P e of Death chlospital nstitution
own or Vil age Qj c e1 J Feu,_S TT St eet Address �Lfe-U Feuvs
-,.. anner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
4_ P4AR.- 3 ki-c4044,41„,i
Address
hilt3 ?(o7 / -i J'o-, G3, t_ -..13 Q tm.� , . 1ZJPI--
< th
'` Certificate Filed 1,- District Number j i gist er
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i City, own or Village �G�iJs F � '_
Date 1 Cemetery o Crematory
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❑Burial -.__-- � _ _ h„)a-Vr
Address
Cremation j U je. �-y _._ e15-"
Date /l t v 3.Q L Place Removed
O❑Removal and/or Held
and/or i Address
— Hold
0 ! Date ' Point of
N❑Transportation i Shipment
a by Common Destination
Carrier
C Disinterment Date T Ceretery Address
Reinterment Date Cemetery Address 1
Permit Issued to Registration Number
Name of Funeral Home.AJCt`/na rd 6• Ie1 FL.cne'ra/ Home 1 CI i C�
Address l Lafar c�C C r
ya1C a+. , & ,�S/a.,c (j , tiEw /.)r JC- 1.2AZy _
`. Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above J
Address 1
A
;w.Y Permission is hereby granted to dispose of the human remains described above as indicated.
<; Date Issued 9 ( ZI I o/ Registrar of Vital Statistics WCA.kii-vA. ��/-^
(signature)
Eit District Number 5 60 I Place 6 (52.), S \`S , 11J y'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition '/`i/Pi Place of Disposition cC,,A2f
2 (address)
LUl
S)
CC (section) (loyumber) r (grave number)
G Name of Sexton or Person in Charge of Premises t%fir» -
,
Le A�- (please print)
Signature v Title CI'L►i fll
over)
DOH-1555 (9/98)