Denno, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Midd�l Last Sex
s J
Date of Death Age If Veteran of U.S. Armed Forces,
,/ C/ '),o/4/ 6 7 War or Dates
i-4. Plae of Death Hospital, Institution or //,,
Z��City,�,�Town or Village ck('cti° /`rn treet Address � t7�5`
p `Adatfner of Death Natural Caus cide Homicide ❑Suicide ❑ determined❑Pending
��
LL! ,� Circumstances Investigation
W Medical Certifier Name Title
CI 0.1 ALA 5A ee 2ey pip
Address / ab
Certificate Filed Di'trict Number// ) Register Number
Wi own or Village �wn�.-}a e,72.,-- V ` S c9
['Burial Date J Cemetery or C atory /'
❑Entombment ! l / of i ;`6e-Viei..J C./'{M r
Address
[ remation ,.a,e-e isA & Y
Date ) Place Removed
Z Removal and/or Held
2❑and/or Address
F_- Hold
O Date Point of
fii❑Transportation Shipment
▪ by Common Destination
Carrier
❑Disinterment Date I Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home eP-CA 5,11 ire I-I3 1` Oo`t1
Address
7 S-AciA4qt Ate) Coy ,& N, r / ax��
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g Address
t
Lu
Permission is hereby granted to dispose of the human remai es ri abo as-indicate
Date Issued L/ 7/ /7 Registrar of Vital Statistics "y
(signature)
District Number L/-S p 1 Place c_cQi‘ f /0 X
I certifythat the remains of the decedent identified abo0�k wer disp6�ed of in accordance with this permit on:
F-
ILI Date of Disposition ;2Ii1 IN Place of Disposition 't„I(,,,,i C4 f„_,
(address)
li
LO
CC (section) (lot number) (grave number)
O Name of Sexton or Perso in Char a of Premises ///L1 ,,..
(pl ase print)
l a wi Signature -' `- Title kat„• i.
(over)
DOH-1555 (02/2004)