Dickinson, Burce NEW YORK•STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First L13/ Middle Last /9• , • Sex
Al t CQ� �NLea-n-). `-7)121--eJ
mi Date of Death / /1,6,2/0z0/.Lit Age .�/ If VeteranofU.S. Armed Forces, .C� War or Dates
14 Place of-Death Hospital,re A Idies utL i4� d /,z' it -.-
. City, Town or Village T/0 GUILDERLAND Street Address uL°SPending�'
Manner of Death . Undetermined
La Natural C�u3� Q Accident 0 Homicide �Suicide Q
tE • Circumstances Investigation
.a Medical Certifier Name acez. 4 Tip
1gB01 ecj ,c.;, tss . ,�
., 1t , (c)/0 '
iii Death Certificate Filed . '' District Number Register Number •
iiii City, Town or Village T/O GUILDERI AND 155 /1.77
❑Burial Date Cer�iehgry or Cremato
#< 0 Entombment Address - '1411
Cremation 24U
Date Plac. Removed •
❑
Removal and/or Heldiz .
3 and/or Address ` ,
Hold
0 Date . Point of
i n Transportation Shipment
i' by Common Destination
Carrier
Q Disinterment Date Cemetery Address
" Reinterment Date Cemetery Address
_ Permit Issued to Registr Ion umber
::':-Name of Funeral Home (/' -, ,riex. Oo 64
':< Address /iO A/I _ 6 a.4-'ii % l .c jC � 71/- /a9e(a6
Name of Funeral Firm Making Disposition or to Whom
f'- Remains are Shipped, If Other than Above
2 Address
Ct
Permission is199h eby ranted to dispose of the human re 'ns descr' ed/a iG�ove as indicated.
iiii><< Date Issued /o- a /7 l Registrar of Vital Statistics r _love
aii
• `<[ District Number 155 Place T/O GUILDERLAND, . BO 9,, GUILDERLAND, NY 12084 O339
I certifythat the remains of.the decedent identified above were disposed of.in accordance•.with this permit on:
1- ' � �^
li[ Date of Disposition. �.2 1 L3�I`,t Place of Disposition • ,�cVtc.4i
C.-tcra,_
•. (address)
Ui
U)
i (section) - (lot number (grave number)
0
ta Name of Sexton or.Person ' Charge o Premises z+^ a+^
(p ase print) •
mi Signature Title M%''' "' '
(over)
DOH-1555 (02/2004)