Pritchard, Paul tr.7 /3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death L 2-7Ag 5�__. If Veteran of U.S. Armed Forces,
l t '--�- War or Dates
E. Place of Death Hospital, Institution or
W City, Town or Village qv\-\-- ('\ Street Address
W Manner of Death �7Natural Cause ❑Accident ❑Homicide III Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier ame --., Title
CI `Chard ta rice_‘ \ M D
Address
i'c r' 1 - .
t"l qpri:nqs
Death Certificate Filed a � District Number Re ter Number
City, Town or Village tl/tl \ t*e5l4)' ,;:)_8
❑Burial Date Cemetery or Crematory
❑Entombment lam, l 1ne)Iew re'r'� Y�1
a` ,v
remation Address `f
Date lace Removed
Z ❑Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
.0)* El
Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to z Registration Number
Name of Funeral Home C QrmcS5' '( Or'Q rQ y , -€ OO (ck--\
Address 0 . MCOilA A)e ' O \res
.y
Name of Funeral Firm Making Disposition or to Whom
#- Remains are Shipped, If Other than Above
;', Address
IX
ill
tu
. Permission is hereby granted to dispose of the h em 'ns des 'bed bove as indic
Date Issued 7 ta,c1 ) 1 4 Registrar of Vital Stat. .cs ICA.
(signature)
District Number 9.5(2f Place .`��� pctk,
I certify that the remains off the decedent identified above were disposed of in acco ance with this permit on:
ILI Date of Disposition 7d 9"/ Place of Disposition i( ®d, '
2 (address)
W
Ul
iM (section)Namelot nu per) (grave number)
of Sexton •" -rI• in Charge of Premises 1- ` /
6pie a print)
it Signature A Ce1111;061176171 Title )*-
',iv
(over)
DOH-1555 (02/2004)