Fitzgerald, Edward NEW YORK STATE DEPARTMENT OF HEALTA =- # ` zIO
Vital Records Section Burial - Transit Permit
Name First Middle Last Svc,
, WAR. /24/ fE C-�.�`ZALD PIALIL
Date of Death Age If Veteran of U.S. Armed Forces,
�i, ,/. y,2 0/9 73 War or Dates me)��Q r4
I - Place of Death Hospital, Institute n or
ILICityTw�or Village�/,Q � js jaw ry Street Address/sip/I", /1 J/((,. (' j Qs'L,,
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
La Circumstances Investigation
la Medical Certifier Name Tille
41 /e-oiklRC,o 8 - Ag006-1Y IZOA-1I
Address
Yo , ✓OF—t-j S7 - A)/2414,JA c, LA/cc_.,�l
Death Certificate Filed District Numbey Register Number
City,( or Village /Viel�j(9Jit ) /00-1.
❑Burial Date Cemetery or Cr matory
❑Entombment Address Cremation o?/ (.26)4/e'e.. 6ZL ,riJ'I c eu?/ it /� ! J/
Date Place Removed
❑Removal and/or Held
and/or Address
Fw Hold
0 Date Point of
05. Transportation Shipment
E by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reintermenf Date Cemetery Address
Permit Issued to Registration umber
Name of Funeral Home 1;d , eL,4ra /A L, K'/O 7
Address
3/0 ` iZAL/A C 11,46 A, 11:40, , Ai LZ91//
Name of Funeral Firm Making Disposition/or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
3 Permission is hereby granted to dispose of the human remai described above as ted.
Date Issued(2'O9--J�/ Registrar of Vital Statistics (,��,L
signature
District Number /6°K 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:
ui Date of Disposition 1-5-14 Place of Disposition r J�,`
..i +w'Cofi--..
W (address)
t/3
CC (section) (lot nu er) (grave number)
gName of Sexton or Person i Charge of Premises sty'' 30k✓i"
Z (please print)
Signature r c� Title CiVe_MAgrei
(over)
DOH-1555 (02/2004)