Chennell, Timothy 413
NEW YORK STATE DEPARTMENT OF HEA!xT-l4
Vital Records Section Burial - Transit Permit
Na e First Mi knrdL
Last I Sex
� c.mp�-ht Q , _ ' Mc{ie-
mate of Death .J Q Age If Veteran of U.S. Armed Fe
�-�( 9 - g
0/a %ay War or Dates /'�)Q
i-t Place of Death Lang �� Hospital, Institution or �^
Ci ow r Village 9 Street Address La K &th n epifyl of rc nd
Manner of Death Natural use 0 Accident 0 Homicide 0 Suicide 0 Undetermined etnding
W Circumstances Investigation
ill Medical CertifVi
Name Title
O ('AIn a Uen ni n cA S ✓WAc-
Address
P O bo -2 kJ Y
Death Certificate File di District Number Register Number
City,Lw o r Village�V G L t,ke_. 0 0'5 6
❑Burial Date �J e etery or Cremato
C)t� ao l a ri �� 1 e_� � ol-on)
l-on
:: ❑Entombment Address `-
LPremation U-C-C�S Jou ` !V
Date Place moved
gEl❑Removal and/or Held
and/or Address
i=` Hold
to
Date Point of
CL
❑Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
gii Permit Issued to J r� Registration Number
' ;'� ���' -/Name of Funeral Home -1-o 0 99'
Address
(p57 cSroc 0-e 3a indiaii La_ke_. m /2'8 yZ
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Z Address
CC
U
P` Permission is he eby ranted to dispose of the human remains described above as indicated.
Ei Date Issued R to /0. Registrar of Vital Statistics �!Q- -tje�G �
(signature)
District Number 20 57, Place co t),t 61 Li') La k.—
_9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la• Date of Disposition yr,-It- Place of Disposition Z.Vgw crAorno►..
(address)
fil '
>
cc (section) �/ (lot number) (grave number)
0L/�,
jt Name of Sexton or Person in Charge of Premises uI ("Nit.
e please print)
W 4-fiL Signature Title C i.Ata .
(over)
DOH-1555 (02/2004)
a