Fitzgerald, David NEW YORK STATE DEPARTMENT OF HEALTH/ { s Zn
Vital Records Section Burial - Transit Permit
-
y Name First Middle Last A9LL1
i -S OSt'Pb' r/ T-2_C611A �
Date of Deatch� A If Veteran of U.S.Armed Forces,
7 ) , _ • Dates I ?--7_/ 5r Z
of Death Hospital,'r -titution°rn
Au,: own or Village GE'� Feu_
, ( 'eet Address �f tt-f-S ,t V ,�Ar t i
'' of Death
igNatura!Cause Cl Accident 0 Homicide 0 Suicide El Undetermined �Pending
rn.rn" Circumstances Investigation
j , Medical Certifier Name )� )F Title A
�G
Al, 1) ,
4I1 Address J _
A// - Z Pig
-_ 1 Certificate Fled �� District Number Regis ea i•• •-r
;> awn or Vi S �i
Date Cemetery • Crematory
0 Burial y u / y !,)tc 16i-3
Address rr)) (
I,1r Cremation ( U 6'1- _ f'-p 0 O8ef-1 13 / v• .
Date -Place Removed U� '
4 ri Removal and/or Held
., and/or Address _.
j Hold
d Date aint of
` I P 0 Transportation l Shipment
zi by Common Destination
Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
{ Permit Issued to Home_ Registration Number
Name of Funeral HomeHaA/n rO� Aer Funerd/ o/)30
ri Address // La f' e c3t. 6i Sh r /02
Name of Funeral Firm Making Disposition ition or to.Whom
r
Remains are Shipped, If Other than Above
Address
>w
' ; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Li /Z i /i'-! Registrar of Vital Statistics 11Ju�4(t-(2.
(signature)
j1 District Number 5-60 ! Place 6 C -S -Fe, \\S ;ki
I certify that the remains of the decedent identified above were disposed of in accordance
e with this permit on:
' Date of Disposition ilia IN Placeof Disposition CLL1 Lr•^•,tt •-...)
(address)
so
•11 (section) i pot number) (grave number)
Name of Sexton or Pers in Charge f Premises ,silk,- C0K14
(please print)
. 7
Signature Tide t: MA T1it
(over)
DOH-1555 (9/98)