Doin, Ernest NEW YORK STATE DEPARTMENT OF HEALTH e It 6 g"
Vital Records Section Burial - Transit Permit
.., Name First Middle Last 1 Sex
.::
'::> INN C-ST V e M)►J r tJ i M
>a Date gf�Det� f Agee~ 1 If Veteran of U.S. Armed Forces,
«3 ( ar or Dates 'G 41- - VI S a
Place of Death _ ! • pita Institution or ___-___ _____
' .1 Town or Village 6 L e V\S 'ram\` i Str--• address U LENS ct U. .S i-to s V t TA L
,,- •anner of Death Natural Cause El Accident 0 Homicide 0 Suicide ❑Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name., . Title
YYf Address (00 Vcf\t- St- �(D „5 c..1k I y\ t asd
D th Certificate Filed i District Number 1 Register Number
Ci own or Village ��1 i �«S , - �aD
Date i m C etery or.Crematory
E Burial $ 1 / 9 i a.0\L{ ' pt \)t e_w (sc~,c.4)r
Address GI1
Al Cremation} 1 n
,,. v
Date Place Removed
Z❑Removal and/or Held
v and/or _.____.. _ _____ �____ -
f,, Address
Hold
9 ! Date ?vint of
N❑Transportation Shipment 4
5 by Common Destination
Carrier _
C Disinterment Date Cemetery Address �� �~
Reinterment Date Cemetery Address
al Permit Issued to ' Registration Number
a Name of Funeral Home! /a/na I'd 1). J ake1- Fiij erccl Home CI ) �(�.",
, A 1
Address // L(t.l�a,yc-t Of. , bt e(f) b.c.rc� , 'Vew LJvr)C 1j_yO�f _
>t Name of Funeral Firm Making Disposition or to Whom p — 1
Remains are Shipped, If Other than Above
;:$` Address _________._-__._._ __
n Permission is here y granted to dispose of the human re• ains described abo e as indi-<ted.
>> Date Issued Registrar of Vital Statistics , ,,./ iik. A.,r }
it (sign-,/r.
{'': District Number CJ 1 Place ��/,<....e •,if _.�Ft _
I certify that the remains of the decedent identified above were . posed of in accordance w this permit on;
f-
WDate of Disposition II /5111 Place of Disposition Z;k✓ (4"--C r«.—.
Ste. (address)
U
CC (section) Ot number) (grave number)
O ,Name of Sexton or Person in Charge of Premises 1,,1c, 4 S•Imsi`
Z (please print) 1
Signature 4 4 - Title Cfuf rrf4'(,
(over)
DOH-1555 (9/98)