Fay, David NEW YORK STATE DEPARTMENT OF HEALTH f I # 3 L?
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
BAUiD L . F/iy .LI4o
Date of Death Age . If Veteran of U.S. Armed Forces,
TdC-6j /-2,A0/Z bC/ War or Dates //1./ 'i
1- Place of Death Hospital, Institution or /6/c : i''140ic-A✓ 6j7L_
City,itaii.or Village//Al4,v.F7S70c.JrJ Street Address S 4/►,,,0,JA C. LA/Cep NY /ac, 1
W Manner of Death Natural Cause Accident Homicide Suicide Undetermined 0 Pending
lzsl Circumstances Investigation
W Medical Certifier Name. Title
Q ' /Ci 00A -7o/n&Joov f')
Address
Lei/e____ ece..4 c.2 6;2- - Slvi2,C.✓X G t 4/c.,, fv-/ /�, sc j
Death Certificate Filed District Number Register Number
City 9or Village/i/A,Z ,tee -.176Ldn,7
❑Burial Date Cemetery or Crematory
Entombment N /7 -Z0/ Z, /0/A-1 Ui e--`'J P, %al.,7
Address i
Cremation ..'/ 06,4/car!A_. . ( ciii 6c'rS /✓y
Date Place Removed
.RD Removal and/or Held
and/or
�,,;; Address
CO,
Hold
Date Point of
gi
Q Transportation Shipment
in by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Nur
Name of Funeral Home/414 . e(n/cj 11JC , t3/(3' 7c
Address
3/0 SA,ZA AA C_ ,4)e-, L/4167. /1)6/0 Lie /V 7 /o7-e;/lS
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
to
P` Permission is hereby granted to dispose of the human remains described abo s indicated.
Date Issued 2-/ 3 -/ Z„, Registrar of Vital Statistics K-N(Luez,/,‘_
gnature)
District Number ),/;, Place Village of Saranac La
l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
N/
I� Date of Disposition '}-j1-I Z R
Place of Disposition „J -40�,
2 (address)
ILI
ix (section) A , (lot number) (grave number)
CV Name of Sexton or Person in Char of Premises L nt,*10 - )BN,.c/61-
please print)
Itif AIL
Signature Title cr>,0A7414i
(over)
DOH-1555 (02/2004)