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Davis, Raymond
NEW YORK STATE DEPARTMENT OF HEALTH # �la� Vital Records Section s . , Burial - Transit Permit f z Last Sex. �Q�r\o>J a C11&tz_u.=S DAv t S I N\ Date of ta ti I Age If Veteran of U.S.Armed Forces, �: (U ! -� �O i 5 War or Dates 1q 4 c-4 L. APlace of Death Hospital, Institution or . y4- City,Town or Village Fmk Imo.r Street Address ) -S ��. U 0 '' Manner of Death El Natural Cause ❑Accident ❑Homicide ❑Suicide El U 0 Pending o . r', Circumstances Investigation Medical Certifier Name toe '1 e SAse-vc-•^.5 Title ( 3 Address t©o t re Si- G i,er. rcrtt s, `'t `ago 1 Death = e Filed District Number Register Number inastwy 0-Burial (C) /au /of0I v Cernefery orw-s ce o r El cremation Addresse.r›),_x-V-c5-- Qen `d\ e.c 56-° 13 'l l 1kT 15 0 Date Place Remov 0 Removal and/or Held •• for Address Hold a Date r'ccint of `,10 Transportation Shipment 4$' i&y'C.►t MITr - YA5 2? Carrier []Disinterment Date Cemetery Address 0 Reiriterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Ha.vmrd b• er Fu,nera l /f orr c Ohl 3o Address ,� La e (Y. ,&Lkte_nSiDaild i/UQ.w 'vr1- I affOY- Name of Funeral Firm Ma king Disposition or to.Whom t•N Remains are Shipped, If Other than Above t'. Address uPermission is y to dispose of the human r described abovoes ind' _ � Date Issued /� /� Registrar of Vital Statistics (S ) wy District Number . /.J . /14. '--J A7" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition IC!Z1/rt Place of Disposition gU4L £ -*c• v ... (address) =y (section) LAbt number)., (grave number) a Name of Sexton or Person in Charge of Premises Alto i Mntd a (please print) IT Signature 4 "ci-- Title Ciliemiito'C (over) DOH-1555 (9/98)