Duell, June .1 NEW YCRK STATE DEPARTMENT OF 'HEALTH
Vila Records Sectiur Burial - Transit Permit
,.NaNamq FIIS7 %`1,..;tiC. Last c.,,r.
ex
Dale et Death A. 11 '.) 00Nan (.1 U.S Armed Forces,
..3 -• ZD--?_,C)i 4- /(...t, War dr Dates Ni 0
3-- . .. _ .
.-;; Place ol DE-.:;arti -,uspital Institution or
Z: City ridea; a Vcia1.30 )-0.dle-V Slreet Address / /Do& i---/aciley
141 .
,0 fillarzn.r.r df Deatl[ Natu A ral cauFx, IT_ cnident 1-1 !_ir,rn Icide Ej ,,,,,d,. r i Undeterm-ned D p.."iki ing
UJ ---'Cir...7..t:mstancrs IrT;ms.trgation
la t. AK;a1Ced:ificd Narr . • A 7111F-
Ci ‘ cha I F . 2)01 Mb
A•JdrE1SS
I eiC r ( n`l-P N.\)
,
Death Cendicate Flied Dishic Nunibe' Peg;,;,110 r1Jrrr.:0:,1
i cry r, )ryiiiirje .471ad19 ""/ 5-K if
DB-dried Cat
01rimmunient 0
13
gCremution Ar;rirr".
z 0 Femovai
Dat,, - - ?JD (41-
ne
ut_ailS bck. . ff.ery or rernatory
5
11 •
Plac.: P,eni°veil
wid,or I teld i e_up ,rtryiodio
an<tor - Addr .;;;s
Ica Hold
0
...
FP;irt J1
3 hi pment
Cemetery Address
Cemetery Address .
5 ctigarCrioerrrim Lori DoDaaeits:,:maton
a.DE TDrisal'Inslei:i:cir ', Date
Fri Red dery ent i
Perrnd 16;stiod to Registration Numbe, 1
Name. or Funeral Horn:EA-C.10er Fknera_j "I 1-01114.1 i VIC-
, Adciress c .+p ).1 , c .
-t' LaAcQ__ LiAZZriviL , /\fy
Name ot Funeral Firm Making Disposition of to V.iho--1 /
I.- Remains are Shipped. If Dthe.r th•tan Ahve
2•11.10.
a Address
CC
...
CLi 1
- Permission is hereby granted to dispose of the human remains described above as indicat d.
i Date Issued 5 aal ?If Registrar oi \Mal Siaistics . Z' ....,24.44.4 1
. z;.;onzterc.; t
.i.
Distrim Number 9558 1..);--i_-.-
- - ).--let di ..,.
__
1 rerlify that the rprnains df the decedent iii*;.!ntii;ed at-/:Die were Llisuos :.:1 in iiccor dame with this 1..,%er nu! on
I-
Z n „
Date c.it asposItico 5-ft-ri Plat.: ,:17 Dts;:vmf,i,.t-::.-1Com-00'0'-
2!
wi
0, i
CI Name of Sexton or °ersor in Charge 24 Premises ktri- _....N. .*.iit i
z 1
1 igz.l.f.,-0•-ii,inti
3Li /
r, .-----..)i griature T.'Vie CiZof 11110
-.7.:,OH-1555 :32'200,11