French, Wallace NEW YORK STATE DEPARTMENT OF HEALTH 1 • 1
Vital Records Section Burial - Transit Permit
r.iai Name First /�j�n r Middle// Last Sex
R /L L�L / et it, /., / 1 4/c._
imi Date of Death Age If Veteran of U.S.Armed Forces,
i J'ti. 3 Jo)Z - 8 War or Dates ,W7
gig Place ; :;-'th Hospital, Institution or
g City Town or Village 4--Ah Street Address 4 .
0 Man each® ❑ ?�iv to q/ l[/1/sip` s —
Natural Cause A id t Homicide Q Suicide 0Undet4rmined ri Pending
41 Circumstances Investigation
119 Medical Certifier Name • Title
<; Address T
.„, 15 S A r 12 m 4A/Av,— at. riiff, MY, i z .C-0 I
l- De icate Filed Dicta Number Re�gi�ter Number
�z. C' ,Town 1 Village l 6L ( 7
Date Cemeteryor Crematory
❑Burial 3-An) `ii 2 2-- P/N e ie.u) ( e,n 4-w ,t.y •.
Address • y�
': Cremation - a/Pit_F -Q )OU�"�'1.VS �t�/17 my JZIrIV
Date Place Removed
/
2 a Removal • and/or Held
2 and/or Address
Eft Hold
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date . Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ny��a4 O. s r rU'-.r A t,A
:t„ Address .
1 LA-(k.1 A-t 5'k , a,,,,, .,,,,,- pti , tz toil
::,t_ Name of Funeral Firm Making Dispositio or to Whom
0 Remains are Shipped, If Other than Above
Address
tlg
a Permission is hereby granted to dispose of the human remains described above as indicated.
`' Date Issued t II-4 t c O Registrar of Vital Statistics'-trz..9 c a ,,_
(signature)
:imDistrict Number(9 "-) Place ) 0 wc\ dT
I certify that the remains of the decedent identified at3ove were disposed of i accorda - this permit on:
is /�
Date of Disposition )- 1.-i 1 Place of Disposition 'Nil+e�.•) Cyr i'iv,--
(address)
f
in
„sr (section) (lot number)S (grave number)
1/47 Name of Sexton or Person , Charge of P emises /1c, 'rcp4 i ,r -
Z
(please print) f
t Signatu?eCi
Title C1d,a I»i'-TOO
(over)
DOH-1555 (9/98)