Mason, Charles •
NEW YORK STATE DEPARTMENT OF HEALTH Si I
Vital Records Section Burial - Transit Permit
Name First Middle st Se
14812i-e-S ut,J19.. ,/.)tr )3'46...). / /1 er-
Date of Death i Age If Veteran of U.S. Armed Forbes,
gi i 9 J 2-6/ t( 6 to War or Dates // id-
Place . •-ath Ho ital Institution or
W City, Tow r Village kii�YWLt--Af g U 2�i treet Addre II? S/9 I T)}- J:-/2 T
Manner of DeathcNatural Cause El Accident D Homicide 0 Suicide ri Undetermined Pending
ILIA Circumstances Investigation
til Medical Certifier Name Title
o,tr arvz "Jell/it-) )4 el-)
Address
LIL
Death rtificate Filed / DistricttNumber /' Regi er Number
City Town Village /n &WL S:0Se,v n,5 1z17
0 Burial Date fCemetery or remato V
>.❑Entombment 2,0 ' t / `� ! �"1-J
Address isii$I. /,
Cremation U 04 6 R L3 ( U 'J S 3 U AY/
Date Place Removed /`
Z Removal and/or Held
2❑and/or Address
t Hold
E
Date Point of
0)Q Transportation Shipment
5 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Ell Reinterment Date Cemetery Address
Permit Issued to Registration Number
3 Name of Funeral Home Gy{laf d -0 €t1et t,laber c I &,rr'& 0 i I
Address
>; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ir
ui
Permission is hereb granted to dispose of the human re "ns escribed ab ite as indi ted.
Date Issued jiLt Registsas of Vita4 Statistic 24: _A4/ 0/ -
signature)
District Number Six Le U Place 1/do,ry 5 bo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Uit Date of Disposition g wily Place of Disposition Z,,.,
Cam-
2 (address)
Ili
fil
rr (section) (tot number (grave number)
0
Name of Sexton or Pers in Charg of Premises 4+`449
Z6 ( Reese paint)ia
Signature Title Clmartt 12
(over)
DOH-1555 (02/2004)