Barrows, Warren NEW YORK STATE DEPARTMENT OF HEALTH f 4
Vital Records Section Burial - Transit Permit
INg Name Fir t Middle Last Sex
A/z e ✓ •�A Y/j ,7?2 S
`<' Date.ol Death A e If Veteran ormed Forces,
,
�vem / 1/ .U/V £3 War or Dates
ig Place of Death Hospital, Institution or
City own r Village L/6_ z erg Street Address I i5 Col-it Si—
, Ma Death Lp1771Natural Cause El Accident ❑Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
#3 Medical Certifier N e Title
. r-� &VA it y 01.6
Address 7 ,,Q
l J r � ‘ `/ Ale,, %'r/( /a d'J
imi Deat ificate Filed District Number Register Number
City, own r Village 44fc L. Lf1e_.__ 5 6 5-‘ 1
Date _ Ceme or Crematory
El Burial If /5 ,ate i `7 •n c V,'c.., .--4'4J,
Address
> Ea Cremation v�A 5�+i�
gDate � Place Removed
0 Removal and/or Held
-• and/or Address
Hold
Date Point of
V)Q Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
% Permit Issued to Registration Number
:,. Name of Funeral Home </-7.0JJ/f Jd y� 7'/'era( 74 .e_
iai Address ,--)
,1--- ke 4 ,,,-/"2/1,_ /lir /' s 2 3_ _
m Name of Funeral irm Making isposition or to Whom
'" Remains are Shipped, If Other than Above
Address
M
>; Permission is hereby granted to dispose of the human rerfr �ris describ ,abov as ' dicated.
Date Issued �/w Registrar of Vital Statistics //_ Qze-L, �����,e.
1-7 C
1 Jp jsi ture)
111 District Number v-[ Z Place /`� /` C_ s�-J a 7 /(4/ / b
I certify that the remains of the decedent identified above we isposed of in accordance with this permit on:
F ��((
5 Date of Disposition ►//A,,I f y .0„Place of Disposition ,,V hr.,r CwAare,_
2 (address)
W
CD
Q4g (section) /f(IQnumber). (grave number)
Name of Sexton or Person in Charge of Premises / n.t a
z (please print)
tij Signature Title CIJi$iw1Ar{�il
(over)
DOH-1555 (9/98)