Cook, William NEW YORK STATE DEPARTMENT OF, HEALTH tt
Vital Records Section 4 Burial - Transit ermit
Ise Name firs` ;'I ' Middle n Last Se�,
1/U lit,� �, Q t A
Date of Death Age{, If Veteran of U.S. Armed Forces,
7/13/.24(Z `� f War or Dates
Place of Death ,,�, Hospital, Institutio r �_�� `
W Cit ow r Village ()cLJ5?JIkYStreet Address Z L. ( �'MeAl ...LP-1 VE
Manner of Death Natural Cause Accident 0 Homicide 0 Suicide ❑Undetermined Pending
W. Circumstances Investigation
W Medical Certifier Namep, // aaiiD Title
4 V
Address
gitaotb 14/Y r;er
iLbkA y /z z
Dea if to Filed Dis ict Number gister Number
Cit , Town or Ilage (± CO i 1
OBurial Date 11 �!Z Certe r rem
❑Entombment r( ���'� Ca 10 /it/t4
Addres
0tremation 2-f GGU4kCK `2Ok, scat seat / (a Y(n
Date Place Removed
❑
Removal and/or Held
2and/or Address
H Hold
O Date Point of
E Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home-294 i ! J�f. 4( - .lht-Q rowo /4�3
Address 5 3 C�l,Q.ii.Gi' �`c Gag as,k ir, kt, /c?�V
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
t
Ili
"` Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued ( 1 '1 / legistrar of Vital Statistics C �� n �--__._.
r (signature)
District Number c Place / 0 __‘ a CD .,,,Q.
I certify that the remains of the decedent identified above were disposed of in accckdan with this permit on:
2
IILI Date of Disposition ')-(' -i L Place of Disposition Prot,O ' Cr^.4,t r1 _,
', . (address)
to
c (section) l (lot number)r (grave number)
• Name of Sexton or Person in Charge of Premises ��1<<�� � J`"
2 4L-- /W,._T I (Please print)
; Signature Title Cdt M'civt
(over)
DOH-1555 (02/2004)