Grimes, Luther NEW YORK STATE DEPARTMENT OF HEALTH 4b
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Vital Records Section Burial - Transit Permit
Name First ddle , Last Sex
Date of D t Age If Veteran of U.S. Armed Forces,
�� �� , War or Dates /l �"
1 . Place, f e / Hospital, Institution r , /7
ifi Ci , Town or Village \c)`j y),(X/ Street Address Y VUY,C) c/'l %i C. c> -��'"y
Mai ner-df Death❑Natural Cause FJ Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
iti Circumstances Investigation
la Medical Certifier �N // Title
Address r ,. V(/fr./). ---3
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MS Death ificate Filed l/ District Number; Register Number
iiMi City, �r Village 6)h/7d arc' Cp ,
iiiii Date ` �/y 6emeta or Cremato / ,
❑Burial �/ _ �� " 4 / 7l, //-,4C/ ( , "7 /c�-�%4/G7.1
❑Entombment Address �/
'"'9Cremation gi.,2%'1�,��i--7/ G%4• v ./v r'/)--")`�77
Date Place RenioVed
gEl❑Removal and/or Held
T and/or Address
cn
Hold
Date Point of
e 0 Transportation Shipment
a by Common Destination
Carrier .
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to /3 —7 _ �� Registration Number
Name of Funeral Homo,( �w,/::?7 ! (:›660Cj_.")� 77,-— /.2.•3 34-)
Address fr ,_
/-
-rs"i C�/�I "✓'46` 7/-)i�✓ �2� 7��r7
mi Name of runeral Firm Making Disposition osition or to Whom
Remains are Shipped, If Other than Above
Address
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'` Permission is hereby granted to dispose of the human
/remains described abov as indicated.
Date Issued 1 _I!i4 Registrar of Vital Statistics � /
6 (si
'`' District Number � � Places 0 �4 n
with this permit on:
'' I certify that the remains of the decedent identified above were disposed of in accordance
k
lid Date of Disposition Willi Place of Disposition ,';ntV1.1 L wc1-os�-
2 (address)
ILU
te
M (section) lot nu ber) (grave number)
si
ci Name of Sexton or Person Charge of P emisesl"'� '� '`''
(plea:print)
gii
Signature ' L Title citotr
(over)
DOH-1555 (02/2004)