Albury, Warren NEW YORK STATE DEPARTMENT OF HEALTH l l
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
VV/AIW-AV HAJZSNALL (IL 2v2y H/JGG
Date of Death Age If Veteran of U.S. Armed Forces,
f tL !cam Zp/9 —77 War or Dates AJ/4
}- Place of Death Hospital, Institution or
Z City,eiSth or`.Vittage/4ivt 07ST)t Street Address/30x li ,p1GA L., _"Qat a.
AManner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined ri Pending
UJ Circumstances Investigation
Li I Medical Certifier Name Title
Ca ,c)ZA ( /uvct`/ii ) HD
Address
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Death Certificate Filed District Number l j,( Register Number
-city, Town a iilage f,1AR71U1 fbG1l✓ ` ti."�
0 Burial Date �0 o20 l y Gebel or Crematorytij C/7- A rO
itil
[]Entombment Address J"'//
Cremation c2l Q Vi /Ge•/l- /Z4/ -lJeell-J&/,2 2 Aix/
Date Place Removed
''.. ❑Removal and/or Held
Y and/or Address
HHold
(I)
0 Date Point of
Transportation Shipment
ca by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home/Li,J3. & A i2/ . j/vG ,
Address
f 310 s A/ZAAM At,� , ZAIc, Pa0.�, p f / ' a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
it
Ili
Permission is hereby granted to dispose of the human remains de cribpd above as Indic ed.
Date Issued,-..IO-ob1 y Registrar of Vital Statistics .sue
(signature)
District Number/ 6 3 Place Village of Saranac Lake
I certify that the remains of the decedent identified above were disposed of in accordance
with this permit on:
v'���� 4y Cr iars....
Date of Disposition ��� Place of Disposition �L+�
(address)
ILl
0
CC (section) 'lot numberr' (grave number)
a Name of Sexton or Person i Charge of P emises 'lot
r e,w#
Z (p ase print)
Signature Title aFkleie.
(over)
SOH-1555 (02/2004)