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Hoyt, Karl
f'► ii,D NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial Transit Permit Name First Middle Last Sex '�� L7 Hayr /�'1 Date of Death Age If Veteran of U.S. Armed Forces, __ �`'� Zv/�/ gd War or Dates 4 Place of Death �/' OL G Hospital, Institution or City, Town or Village Street Address 2 S' G/<-'2 S .t om or Manner of Death©Natural Cause n Accident 0 Homicide 0 Suicide O Undetermined O Pending Circumstances Investigation Medical Certifier Name Title &E.D!!be S/NistA.e.1,v At. Address jam, t7�-�`71 Af-fe_m�� ,*i'Gt Cdj/ii"1-' A'y Death - ificate Filed District Number `f 5S— Register Number City, _own • Village �.-�A,rA,Lc. ;--..OBu '..-- Date Cemetery_or Crematory DEntombment 1 6 1 4 A a t i' «(`1//c -' G, �� O-el Address NCremation 9/ 1-1/3c' -re N . 'j' Date Place Removed ❑Removal and/or Held and/or Address Hold IR Date Point of gg1$. Transportation Shipment by Common Destination Carrier _ IlkDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to _ _ _ Registration Number Name of Funeral Home D _ �44O'C �UN4X�`L /OAfC e, 0 yf'`fg Address 7 N.Rmrl/v i9 c o,Z/,vim- /-/7' /AR2-1 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ' Permission is hereby granted to dispose of the human remai s described above indicated3, Date Issued /J5. . /L/_ Registrar of Vital Statistics (' (signature) s District Number /5 5 g Place ---‘t__)--k, certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition i A i 1py Place of Disposition ZA a+,/ e,f,— FY (address) ir a (section) of number) (grave number) cf Name of Sexton or Person i Charge of Pre ises ' f Sam (plea print) Signature L Title CGCml<trat LI (over) DOH-1555 (02/2004)