Girard, Zachary NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section 4
Name Firstr7 L ILIdle A Last Sle c
4ID
�./ Date of Death Age. , If Veteran of U.S. Armed Forces,
191,'ZZ-ZD jZ `fG^ War or Dates
Pl.ce of Death Hospital, Institution or �
own or Village N1--4,�/ J J Street Address f t�A }�
y/ i"+ 19Ar- ti _
Ulf
a ' •nner of Death❑Natural Cause a;;Accident 0 Homicide 0 Suicide riUndetermined FlPending
iti
Circumstances Investigation
iii Medical Certifier Name fo Title
Address
P I Certificate Filed District Number Register Number
..:::::: DIP own or Village rk-97 Any 4
. ■Burial Date Cemetery qr prematqk
0t—'3a - Zv1,v 1'1 , Vt t vwATOTJ
❑Entombment Address (" /
qi VCremation ��v VD, (/�.�,24moSa+m�ll P if
Date Place Removed
❑Removal and/or Held
and/or Address
r.: Hold
0
0 Date Point of
OS Q Transportation Shipment
a by Common Destination
Carrier
>>!Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to /�fi / Registration Number
Name of Funeral Home 4"t .�, I`� )i-r�► L. V}�Wi NiE of- A?��
Address V u 4 ) stir riP1•o14m A.)Y 2d
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tC
fU
;> Permission is hereby granted to dispose of the human remains described abo as indicated.
446 Date Issued l Z3 7?ULZ Registrar of Vital Statistics -� 4 °1-
gnature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E /�
tU Date of Disposition I/31 /Z D Place of Disposition T ,4 UV .. L-t+�teia ni..
2 (address)
L
CA
tC (section) (lot number) e- (grave number)
CI Name of Sexton or Pers in Charge Premises 4t st ,- Jev►refk
aL (please print)
I>1E Signature �`/ Title C�Ll�m I.(
(over)
DOH-1555 (02/2004)