Arnold, David NEW YORK STATE DEPARTMENT OF HEALTH ��
VaalRecords Burial - Transit Permit
Nye First
Age tf Vetere of U.S.Alined Forces,
e�fDee#n0Z) 20 1 )4 1L warorrra )9 5(0-laS
Place of Death Hospital,Institution or
Cily�;'room or vdage G\ein5 Fa.\\S Street Address -ITT_ P r n e S-
- Mannar of Death 14Natural Cause EAccident p Homicide 0Suicide p u,-,aekr, a ['Pending
Medical Certifies' twine Cicumstances investigation
Title IA- i,,,Address`-
7 ri m e t\• ( a\) esy,
110 NiQaffen SSA- . G b2ns c s -A )2-gp1
, Death thy.Townerlikate Filed V C1 LQ S pot\\S Districtr ml�er 560 i' -,�.'.'' g-
... natory
IlB� > e CO - -1 , I 4 Cemetery eti.1 Ot-Vor-/
Address
aCremation \1\_._vo(j Alice iF)(ei Jed,
Date
A❑Removal and/or Hald
Hold " '
d
Date Paint of
p Transportation Shipment
cz by Common Destination
Carrier
El Disi:rtennent gate Cemetery Address
p Reintennent �'''' Address
Permit Issued to Registration Number
Name of Funeral Home ittaynard v, der Funera./ Home_ore_ QI 130
l/ La a.y e at ,Outuniourcd'Pau 9or1 /2 O'/
Name of Funeral Firm Making Dispoeition or to.Whom
Remains are Shipped,if Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/2l// 1 Registrar of Vital statistics C&A4
( )
` District Number 5 6 0 1 Place 6 (52/v _S & OS 1 0 1/
I certify that the remains of the decedent identified above were imposed of in accordance with this permit on:
• Date of Disposition ,1 Alf lIN Place of Disposition �,,,t/p.. ��-tx,,. ,
O
(section) _ (lot �')� (grave number)
a' Name of Sexton or in Char 'of Promises ;f ill,..
D
.::. Title 404Iffret
(over)
DOH-1555(9/98)