Noxon, Edward NEW YORK STATE DEPARTMENT OF HEALTH f vs4 Ng
Vital Records Section Burial - Transit Permit
Name First A e-� Middle N 6t Est Sex
Date of Death Age If Veteran of U.S. Armed Forces, (�
G 9 Yc7 — ��
I dg. 9c/q 70 War or Dates 17 r
▪ Place of Death Hospital, Institution or ,/�
iTi City, Town or Village SGi 1.--0 013 Street Address G7 7 iVO eR 6 l J if e._,
• Manner of Death pjlatural Cause Accident Homicide 0 Suicide Undetermined Pending
W Circumstances Investigation
la Medical Certifier me Title
t l!"N(I/ 44 �'�'l ll &) 0nD
Address r
76 rn�/o �l 0.4pre, -sAo IQ% / 2 S
Death Certificate Filed District Number ' Register Number
City, Town or Village 4.6 �_
*,iii❑Burial Date // Jr' emetery or Cr dory ,
io ❑Entombment G'_ `� — A71 11l2 Vie-10 ep-'nil�?A !7 p
Address
-emation ave4403 .6 u ►^y .. f 010.1
Date Mace Removed
Removal and/or Held
and/or Address
tris Hold
O Date Point of
fit'' Transportation Shipment
C by Common Destination
Carrier
igiiEl Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
j Permit Issued to Stronq/� Registration Number
Mii Name of Funeral Home irtL Z. ei fV Ne Via( J jtije— del l 7
Address
0! ...c() 11/4 id-- /1/4-)-7- / g--Cf- 7
Name of Funeral Firm Making MOsition or to Whom
_• Remains are Shipped, If Other than Above
• Address
tr
1 Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued t/-e3- Q// Registrar of Vital Statistics co CA_it, .1 e
(signature)
iiiiig District Number 15103 Place 3W kO>92/1 A)--_,>/-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �f �
Ut Date of Disposition A 3 IN Place of Disposition 'L'�ttl�,v C.mc f rca.
(address)
tLf
(section) /114
(lot umber) (grave number)
ti Name of Sexton or Person in arge of Pre ises � �e'n140
(prase print)
Ill
Si nature Title �t0C
(over)
DOH-1555 (02/2004)