Meanor, Earl NEW YORK STATE DEPARTMENT OF HEALTH Tf QS Tr It
an Records Section BurialT Sn it Permit
Name First Middle ce_ lit co� Sex M
`-'.. Date of Death Age If Veteran of U.S.Armed Forces,
o f 105 j 2 0 '4 , t 2, War or Dates h11 Y‘now n
Place of Death CriospitInstitution or
" 40B70TownorVillage G'iji.r]S Fak‘S Street Address GLeg peas 4-kosf 44
.w 1-1 Undetermined Pendng
Manner of Death A Natural Cause D Accident Homicide Suicide 1-1 Circumstances ❑Investigation
Medical Certifier Name Title
M tr r1 David OV , 1 1-A
Address
r•
k Soo Pct r vc. SI-- G F ivy I 7.-&6 1
-Tiil irrh•n.th Certificate Filed District Number 56 G 1 Register umber
:;` ib own or Village Filed,, District
Fall
('-'� Date Cemetery or ema o
El Burial 61 , ° $ ) 2.614 f it n c V 1 tG k7 nom a i r`y
Address
p Cremation Qu%eeftSbur1 , Ai .
Date Place Removed
49-4❑Removal and/or Held
and/or
Address
r~ Hold
d Date I Point of
Transportation i Shipment
,;•4 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
`;t Permit Issued to f Registration Number
X Name of Funeral Home Nara rd v ker �c.c nercz� Home_ QI 13(
"il:0 Address a Lafa i j e c3f. , &U.I ernsbu.rc ,New zlvr)L 1 'Uy
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, if Other than Above
r Address
tsz
t
Permission is hereby granted to dispose of the human r ains d 'bed above asliinydiica ed. ,,�,
Date Issued Registrar of Vital Statistics ll( 1 -ice-, ,!/✓ /24-
(signatur
s
District Number�'�,Q / Place Li2,Q --II
I certify that the remains of the decedent identified above were di ed of in.accor with this permit on:
• Date of Disposition 1 /9 III Place of Disposition mWs+�., 1
(address)
,x (section) ef,(1c1 number) (grave number)
o, Name of Sexton or Person i Charge of remises r - "'"�
- i (please print) •
Signature G
L Title LAY/1"de.,
(over)
DOH-1555 (9/98)