Blanchard Sr, John NEW YORK STATE DEPARTMENT OF HEALTH 41t6 g 730
Vital Records Section Burial - Transit Permit
Name First Middle I act �� Sexli Date of Death Age If Veteran of U.S. Armed Forces
11 a5 J t y ( or Dates
ce of Death Hospital, stitution or
City. own or Village G t-_ S E/S t_l_S Street Address G.-E�5 V A t_.L-3 Iyc5P iz-A c-
r of Death Undetermined �1 Pending
Natural Cause E Accident 0 Homicide D Suicide ! l 1
ill _,__�`�_ Circumstances __ Investigation
Medical Certifier Name Title
inAZZ\.3tLi 10iav‘ rwt�� 0 Address ,
LOC) Q r��t , c,LC' 5 V A L-L.s �.y_-\D--kO)
Death Certificate Filed ` District Number Register Numberbq 2
;` City, Town or Village {
1 Date / C metery Crematory
Burial ri \\*\e�
Address
Cremation i ,,cue ,,s 2�O
Date Place R ove i
Removal and/or '-ieid
•.. and/or f Address s__ _. _
}- Hold
O Date it d ,f
(/) t l• Transportation Shipment
by Common ! Destination.
Carrier __ '
Li Disinterment Date Cemetery Address
` - Date Cemetery Address j
Reinterment
Permit Issued to , Registration Number
Name of Funeral Home k/ '-%rla rCI b / aktf t• .---- i`«I //L?tv C_;1 ! .L __
Address /
Name of Funeral Firm Making Disposition or to Whom
:- Remains are Shipped, If Other than Above _—
•6` Address
Permission is h reb granted to dispose of the human r mains de cribed abo as indica
Date issued /' Registrar of Vital Statistics --
(signatu )
District Number ,,'` / Place—_
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
ail Date of Disposition I f f 1 J/ Place of Disposition 4-./ t iw ``•^ _ __
{21 (address)
LIJi
10
cr (section) Xt number) (grave number)
O Name of Sexton or Person in barge of4 Premises ___ _ -Si�.r&f _
(please print)
iZ — CIM - .
!LP Signature Title__
over)
DOH 1555 (9/981