French, Arnold NEW YORK STATE DEPARTMENT OF HEALTHS # an
Vital Records Section Burial - Transit Permit
Name First A Middle Last Sex
Irnc)l 6 Ei rd .renc vl IA
Date of Death Age 1 If Veteran of U.S.Armed Forces,
03)a-lo J 9..01,4 War or Dates NI A
Place of Death Hospital, Institution or
•
' '`-?► own or Village G I-enS P'ot AS Street Address ( I Ins P41\s asp i \
Manner of Death C Natural Cause Q Accident Homicide Suicide D Undetermined 0 Pending
Circumstances Investigation
• Medical Certifier Name -� Title-�Ar e\ \Oc y M
Address
\(DC) Pet i-\C- 3 -ee-} C LQ.nS 1=�a\ls NJ 1 zgoI
Certificate Filed District Number Register Number.
': Town or Vide �\enS Csa\\S X D i
Date Cemetery or Crematory
El Burial I �, ,Burial 1 P.►r)e. \J.,-Irv: C.rema
Address
2J Cremation @.,.rA\maw a.,0041 C3 v.�st.�ns'-b w i N. 1 _ !2.8'O i f
Date Place Removed
D Removal and/or Held
and/or Address
ri Hold
Date Point of
0 Transportation Shipment
a by Common Destination-
::-::::
Carrier
Q Disinterment Date Cemetery Address
Renterment Date Cemetery Address
:rye' Permit Issued to J Registration Number
`L Name of Funeral Home Ha f Ord v' er FLuier, / e'lf- - _ Oil (),
Address 11 La iati e (3. , &ULU/Sbu-nd 1 New tkrk- /2'Qy
• 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 remains described above as indicated.
Date Issued J -z 77 / 19, Registrar of Vital Statistics \ .),-)'' 'R- _-.) `o-
(signature)
' District Number 56o I Place 6 S {G \:\S , &;' y
:.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 Date of Disposition`jc)E/(� Place of Disposition e� lt1 L �f j 1 ( iriil'i5./
(address)
to
(section) ter) (grave number)
P Name of Sexton P i ge of Premises ��(sr �/� �
2 J (plea print) /'y Y.
4! Signature G Ci Title l fW !/'JAC- 43
(over)
DOH-1555 (9/98)