Banta, Edward NEW YORK STATE DEPARTMENT OF HEALTH{ Burial - Transit Permit
Vital Records section
Sex
Name First Ea��1-6 Middle Last C3a�A-o` M
41
ra.,-1 Date of Death Age If Veteran of U.S.Armed Forces,
pa.,al-4l a.Gy`� 8y War or Dates
M Place of Death r� Hospital,Institution or
4 City,, t , Vil • - �l VaJ Y>S'Oi r Street Address t .0 C.CO r 1r\ f-2NGo.C\
tw Manner of Death pet Natural Cause El Accident El Homicide E]Suicide []undetermined ri Pending
Circumstances Investigation
yv-.
` Medical Certifier Name k Title
Joh P• S\-.
w‘e,nb4t►'
Address
iO L- Qo, -• S\-. G�.nS Tek\\s i NI.�� •
zAr r`�
VDeath Certificate Filed (` District Number Registert Number
City, or Village vl� U4'f-y 5 / �`
Date Oa-\� \ a o•\` CemeteryP.\ e Cr 'CU.)atory C° rQr(l o ar
=:` 0Burial
Address Icy
Cremation e aNt\-ea " 1 Sbkv-y ) 1 V
Date Place Removed
�' Removal and/or Held
s and/or Address _.
ri Hold
b: Date I Point of
`i 0 Transportation Shipment
RW by Common Destination
Carrier
Date Cemetery Address
:_ []Disinterment
El Reintennent Date Cemetery Address
` Permit Issued to ,t! Registration Number
Name of Funeral Home Hcynard b. maker Funeral nera/ Home_ of i 30
Address // t_arc ya#e t+. , &Gte,e,ns un j i/ e-to York- l a 8UL/
y} Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r descri to a 'ndicated.
di
Date Issued ),` � d`4 Registrar of Vital Statistics
kti
gna
14 District Number S iocl
Place 410
_ I certify that the remains of the decedent identified above wer isposed of in
accordance - is permit on:
" Date of Disposition a /a(o II 4 Place of Disposition `t� 0"`-1 •mow ',—
I; (address)
'y (section) 7 tot numb (grave number)
•4 Name of Sexton or Pers - Char a of Premises L h It) r e 16^1 a1-
a•' (please print)
Signature Title nicinPr O)2
(over)
DOH-1555 (9/98)