Clothier, George lit
NEW YORK STATE DEPARTMENT OF HEALTH E # `413
Vital Records Section Burial - Transit Permit
Name First Middle )7 Sex es
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>: Date of Death V Age If Veteran of U.S. Armed Forces,
l a -02 9 oZo// 902- War or Dates /9,Y3- yS
1- Place of Death Hospital, Institution or /
W City, TC r Village QVee,i, /),V Street Address Z j y/�/ / 1L"3j )1- /Qe
O Manner of Death Q Natural Cause Di Accident ❑Homicide ❑Suicide ❑Undetermined r ri Pending
til Circumstances Investigation
W Medical Certifier Name Title 4112.)
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Address l
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Death s irate Filed District Number 1 Register Number
Cit iimni .' Village Qsvi jctV^ ;/ i IS-
❑Burial Date j Cemetery or Crematory
['Entombment t o / 3 L) `t r rt 2Vt 2vJ C"e►-reti0('�/
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Address
I1Cremation e,,ii i)cI / A),Y.
Date P ace Removed
❑Removal and/or Held
and/or
�;; Address
Hold
1.4
O Date Point of
tL Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Ni giber
Name of Funeral Home ,�P-v2'rylo,''� r+`i-Q / ..i`1C ; 0v`t`fK
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
lI
Permission is hereby granted to dispose of the human remains d ed al) ski ed.
Date Issued I2,-aC?- )4 Registrar of Vital Statistics �
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--(signature)
District Number SU cl Place 4p Dtes,woutik
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i_:.:.,,, I certify that the remains of the decedent identified above w e disposed of in acco danc- with this permit on:
LEI• Date of Disposition ILI3G/Pf Place of Disposition :u,.„ , ,-tors.
ii ' (address)
UI
CCW (section) Ai).i._
number) (grave number)
Q
p Name of Sexton or Person . Char a of Premises -* [
Z _ (please print)
W. Signature i / Title t'p;/PMR A
(over)
DOH-1555 (02/2004)