Larmon, William lir
it as
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ame First Middle Last Sex
IIiary M tQ.r mnr1 pia ire
Date of Death Age . If Veteran of U.S. A ed Forces,
q' 3-- / Y' 7 0 War or Dates I LS D . r 9 01-
1- Place of Death ,i ,, Hospital, Institution or
W LLT1.City, Town or Village K.Q. 1Ze.rne, Street Address 33 05e .
W▪ Manner of Death❑Natural Cause ❑Accident ❑Homicide yi Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
ul Medical Certifier\ Name _ Title
t ITV t I I 1 GL i'y1 1 (O r .1 C1` n 11 rr-rye t.
Address
268 �a.-r-rOu)Sv< ik Rd Skr vn Ny
Death Certificate Filed Distri hu r Regi�er Number
City, or Village LLIze--�'� 0m0 \:')
❑Burial Date /� -7eteryoy Crematj
❑Entombment o_T P 0 / - 2011- I / r Y i et() 1A C��1
Addres
remation uQe as bwru A
Date Place Removed
Z Removal `J
❑ and/or Held
and/or Address
N Hold
III
O Date Point of
5 0 Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to R istrati Number
Name of Funeral Home j--3 itivm ' ryxr14-joryje7 Inc Address lit 1 LIr(/- 5L G akL L uze me N /2 %'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX.
W
fl' Permission is hereby granted to dispose of the hum re ains descr d ab• e I indicated.
Date Issued 9- 7:,t)//Registrar of Vital Statisti s ;A ,e,0efi---71--(P
(signature)
District Number 5 (p Place , 0 upry �Ce bk7--LI— - / v
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
Z
Date of Disposition 4 J INS Place of Disposition goOtiv,, a„aitofw--
2 (address)
iil
0
CC (section) (lot number (grave number)
• Name of Sexton or Person in Charge of P emises ALITL.- -Z ( lease print)
liiii Signature n?L_ Title c �Z.
(over)
DOH-1555 (02/2004)