Loading...
Clements, John NEW YORK STATE DEPARTMENT OF HEALVH ' a R Vital Records Section Burial - Transit Permit Name First Middle Last Sex, ahY'1 b C I� � S '< Date of Death Age If Veteran of U.S. Armed Forces, 3(2-a/ /4 SL( War or Dates { MgO tb1 Place of Death Hospital, Institution or ii City, Town c Village _c , 6LeAs 4- --- Street Address /.»ice sik„ Avt..� •�- 1I Manner of Death [j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undeter fined El Pending W Circumstances Investigation Medical Certifier Nam Title O Ja11N DLL", ^-1-L Jp„ MI . Address rime L. S... ft 3.)O ) S )40 +� 1• );1(6 6 Death Certificate Filed District Number ) Register Number City, Town or t iIlag� s.,. GL-r�, _ 4-SaLl" S . mate Cemetery or Cremator ❑Burial 3/31 /a')'1 ,'n c V;t� 6.,...•(-f r Address ©Cremation C � Le_A� IJ.,,i, ) /Ur,,,, X Date \� Place Removed 0 ❑Removal and/or Held -- and/or Address = Hold U) O Date Point of N ❑Transportation Shipment G by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to �— Registration Number Name of Funeral Home. ,.15n^o rt _ !-/- J d ®'4'1 iii Address N 0 >:.>_ - SLe'er"'. Avg . r.° � Y (a -�� ><= Name of Funeral Firm Making Disposition or to Whof C. n Remains are Shipped, If Other than Above Address CC IN Permission is hereby granted to dispose of the human ains describ abo e as indicated. II Date Issued<3/3)l J y Registrar of Vital Statistics (signature) ` / District Number - )(4 Place �� •1 G1.e/'JS 1 1 S Vi]i2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F � W Date of Disposition 3131(I'f Place of Disposition �[,L,tL., C.-rik, (address) w CC (section) (I number) (grave number) GName of Sexton or Pe on in Char of Premises ,t7, �g.,.wA� (please print) W Signature Title Cp./'tvdt, DOH-1555 (10/89) p. 1 of 2 VS-61