Burdick, Francis NEW YORK STATE DEPARTMENT OF HEALTH e 8 tr.
Vital Records Section Burial - Transitermit
Name First Middle Sex
�i''A&iC/{s � La t i ck
Date of Death Age If Veteran of U.S. Armed Forces,
0_3 e n V- P-o i'' ?6,. War or Dates lea,-ea& 16 A t-- - 1 757- I'1 "
Fs Place of Death Hospital, Institution or
City, Town or Village 5 G4 bo O 0 Street Address i /f Rive, fa A)
IliC Manner of Death r�� atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 1-1 Pending
Circumstances Investigation
tg Medical Certifier me itle
o �hAtJ&CAJ `tre, �A
Address
y 61 t-F,e-t c- A de- Po � c4, j /14 , j ( : 70
Death Certificate Filed District Nu b� Register plumber
City, Town or Village 6� Numb
,
❑Burial Date /
Ce ery or Crematory
oli❑Entombment MArell j� 2.0 144 I N q,v/ ( .� t he r,�-,A y//
Address Ai
;;:;;;;Cremation CA/ tie easb UV'y -y '
Date / Place RLmoved
is ElRemoval and/or Held
and/or
� Address
Hold
O Date Point of
t ❑Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home E4toA)4 k. Kt GIFV wers/ 14ON€___ of 17
Address j
Li4 Kt- i\-))( - / 2 6-7 6
Name of Funera Firm Making Disposition or to Whom
#r- Remains are Shipped, If Other than Above
2 Address
1
t
` Permission is hereby ranted to dispose of the human re ins described above as indicated.
Date Issued 03 166 )Q 141 Registrar of Vital Statistics at-ivz,A1. cutiQ
7
signature)
District Number (so3 Place SC k*-Qi-1 1 ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fJ Date of Disposition 3 l�-/$ Place of Disposition A/1 / /egirnavie_
(address)
Ili
V) 9
IZ r / (section) (lot number) (grave number)
Name of Sexton o er-( �" Charge of Premises
/ (please print) /
Signature Title (please print)
(over)
DOH-1555 (02/2004)