Blair, Philip r R
NEW YORK STATE DEPARTMENT OF HEALTH fr Sy
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t
x
,\', P -WI eo BIc; ✓ M
Date of Death Age I If Veteran of U.S.Armed Forces,
CA Z p 2,6 i ID Z War or Dates t`.1 -
Place of Death Hospital,Institution or
City,Town oc Vil ( E C7 co it ii E Street Address �1 n'1 c Ca;li:s A.rz .
Manner of Death ;&._
Natural Cause 0 Accident El Homicide ['Suicide rl Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
DG►N>A �utttlYh,/9 n m fh/,)
Address
3 ) ron c k- Co,r14-cr Q 1vivs w..5) N
Death Certificate Filed District Number 'Register Number
City,Town or Village G 1051 _ I
Date Cemetetx or Cremptory
Burial 01 i 2 i ab I y Fri n L V,..e C/►-e rna zsY y
Address
: i 9tQ Cremation a vX.v;rx:C\ot...r 1 $0�{
Date ,J t Pla Z.e Removed
a Removal and/or Held
and/or Address
Ef) Hold
Date I Point of
Q Transportation __ 1 Shipment
8 by Common Destination
Carrier
:: El Disinterment Date Cemetery Address
::: ID Renterment Date Cemetery Address
Permit Issued to ` Registration Number
/
Name of Funeral Home aynard v• Fw er er mom QI 130
Address
11 LKzfa_ Otte �. / b(k-uv- u ,New LAVA- 1a'0y
Name of Funeral Firm Making Disposition or to Whom
;x' Remains are Shipped, If Other than Above
Address
., Permission is hereby granted to dispose of the human remains d "bed above as in icated.
Date Issued /?/-/ Registrar of Vital Statistics YY7-7 a. 1Ie2a-5L/
nature)
�- 520 S Place A��.
District Number
I certify that the remains of the decedent identified above were dis of in accordance with this permit on:
f Date of Disposition i/i IN Place of Disposition e r av'(ofo`
2 (address)
ILI
fA-
(section) Iot umbe' (grave number)
SW Name of Sexton or Person in Charge of Premises s o
Z (please print)
Signature filLTitle alCiii►ft
(over)
DOH-1555 (9/98)