Morrisey, Dayton NEW YORK STATE DEPARTMENT OF HEALTH it 47
Vital Records Section Burial - Transit Permit
Name st Middle Last Se
poi ri1 / 5-
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Da of Death Age If Veteran of U.S. Arme Fsrces, /
o C�t- 1 ,i/ j War or Dates /7,_5 j— /,c5�1'
Place .^Beath ! Hospital, Instituti• i � �� `/ ,
City, To or Village \ 0/ //// Street Address, f697, A /' 4' v 4 C i '
.6., Man'-r of Death atural Caus=' Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier _ e itle
.: / y/--.7-• ,_r- /14, //4/7 ?-7 ii7i/7/
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Death CertificateFiled __., District Number Register Number eci
; City,( ow or Village d n ,fZ 'v ', �
Dates/._, / . Ce+ eter or Crematoryy ,/ �Th
❑Burial :/0)'") �(c / ' �� 1 "Z�� !/ /-(ia'/ t/�/,Y94,i'ii
Address
remation - t f U. 7 _� �/ .
Date Place Removed
t❑Removal and/or Held
and/or Address
a
Hold
O Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
... 1-1 Reinterment Date Cemetery Address
: Permit Issued to /,� �--- Registration Number
< Name of Funeral Honu i 797 �� `���%�/�3 /-/-:--;--., k,C 77.41/
,,,:,:,:„
• Addres /' [1 /G� eL LAC,-'2'7 "�'ow
€I' g Disposition of Funeral Firm-Making Dis osition or to Whom
Remains are Shipped, If Other than Above
Address
6a
e.:
M. Permission is hereby granted to dispose of the human re al s described ab ve as indicated.
E. Date Issued / /6-/q Registrar of Vital Statistics ( 6 q, ink,AL
iliiiii (si ature)
District Number 5�- Place ‹ tt gi.-a c§/4 , r Ek Lr
I certify that the remains of the decedent identified above were disposed of in accords with this permit on:
ill• Date of Disposition Place of Disposition
(address)
IU
CA
C (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises
g (please print)
Signature Title
(over)
DOH-1555 (9/98)