Farrell, Walter NEW YORK STATE DEPARTMENT OF HEALTH , -.. id 2
Burial - Transit Permit
Vital Records Section ,
Name First f Middle /, Last S x
��l i ti� t O F�Y�I� / .l2�( x .Y�92 L�
k-; Date of Death Age if Veteran of U.S.Armed Forces, /
War or Dates //,}-
Place ath Hospital, Institution or
-- City�f a r Village Li)o'rwure.J s-fa t n.C Street Address / 0 Z Si ((,k7 V S
>:, Manner of Death!w Natural Cause 0 Accident 0 Homicide El Suicide nUndetermined El Pending
Circumstances Investigation
Medical Certifier Name /� / ;, Title
l(I/9 )Cy- t jinA.) t h .
.4>. Address Z
:. Gix ,is6o , /,i t 4
Dear, : 4 "cate Filed District N`uSm er / Register Number
C� Town. i r Village tJ O'lyl yt AJ.S 7; U 7Z
`'' Date Cemetery or remat � iji
Burial ! //G��iy l /tides CAL-..
Cremation Address ( U`�`l(tit yJ / ) U S es t�� /( ,'� /2 P o '
Date /( Place Removed / '
girlRemoval and/or Held
It and/or Address --
Hold
Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
[�Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home HaA/na rd b. maker Fwiercz/ home_ Of 130
Address /1 LQ 0 L to (3t• , t U./2 Q,nS t-nd , Jti e c) /vrk- i a gOy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a
' Permission is he y ranted to dispose of the human remains d bed above indicated.
' ' Date Issued `I /6 /y Registrar of Vital Stabs•c
(srg re)
I' District Number,j(>(o () Place �.�it 4,tit w1 7I 4- . C/
I certify that the remains of the decedent identified above 4re disposed of in accordance with this permit on:
5 Date of Disposition ci I iiI,' Place of Disposition "t7o law if/�,
r2 (address)
uJ
to
i (section) f (lot numbejr (grave number)
GName of Sexton or Person in Charge of Premises '':sficpitc 'rit
(please print)
Signature Title a,W' a.
• (over)
DOH-1555 (9/98)