Butter Sr, Bert NEW YORK STATE DEPARTMENT OF HEALTH j I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ber-4- O( ;r1 6\4-eAr <)c • k
Date of Death Age If Veteran of U.S.Armed Forces,
,,, CY31 1 1 1 2U 1 4- War or Dates N i A
P ce of Death Hospital, Institution or 1 17-
, Town or Village G l Pn EA.\ S- Street Address C l ens 1,,)15 tUSpi i- 1
Manner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined ending
Circumstances Investigation
Medical Certifier Name ^ _ Title
n n i -cICY n v 1 u 1
Address
co fc cIL 3 . G►cas r k1 ny's s laol
Death Certificate Filed District Number_s Register r
,Town or Village CIens �a\\c L6Q/ /cY
Date Cemetery or Crematory
: QBurial 03\ 1S I a-c Lt P Olt- V i ei.J l_,r`-o-nna+0r
Address n Y
::::: Cremation u GP r I V� ei u.0_11S ►--ry N . . 12$py-
Date Place Removed /
go Removal and/or Held
and/or Address
g Hold
Date Point of
El Transportation Shipment
8 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to ` y Registration Number
Name of Funeral Home f'�s hard v, e`er F iecct/ Horne_ lb(13 i
41 Address // Lctfa y e,#e at , b c.u_e,nSbu ,New /vrk I a eUy
Name of Funeral Firm Making Disposition or to Whom
> :; Remains are Shipped, If Other than Above
Address
r,
Permission is hereby granted to dispose of the huma remain • - - "bed above as di -,•-- •.
• Date Issued a_
�� ��/$' �O/� Registrar of Vital Statistics - c7L..e-�-r�
District Number _��,d/ Place A a G
I certify that the remains of the decedent identified above - e disposed of in accord with this permit on:
ii.4
g Date of Disposition /e"/r Place of Disposition 1 tcit Y / -KJ ect li*ild
(address)
LLI
10
M' r'r (section) v_ (I ber) (grave number)
Name of Sexton or P i ge of Premises _��' t'J ii1'4 l L-I
gl. Signature i' r (Please print) C/ / S f
9 �� �f' v'I1�„ Title , j'!'!/�'`�a��-
(over)
DOH-1555 (9/98)