Arlen, Walter NEW YORK STATE DEPARTMENT OF HEALTH
4tayO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
11,1441E L/L ls)1 Ak2i.,,=nl 6YlAt.Ls=.
Date of Deatl, Age If Veteran of U.S. Armed Forces,
'WV o !4-( War or Dates
1-; Place o Beath �, Hospital, Institution or
2 City, i • r or Village 6 t c,c,1.1 L Sao C A Street Address /`-1 C/Z 1 1 A e,1�= C.,'o i"1'ib(44
Ili
Ci Manner of Death f�l Natural Cause Accident 0 Homicide 0 Suicide Undetermined 0 Pending
�l Circumstances Investigation
la Medical Cetfier----- e ^ ` Title
ta ,Pa , NI[dOr J____________ L) ,
l �, Address
Ail t L(a/ 0/2L"erd 9a , /" /2g'63
Death Certificate Filed District Number15L Register Num er
City, Town or Village /2
❑Burial Date Cemetery or Crematory
['Entombment Vie/ ac!I( P t 6-v tc t�,f
Address
Cremation aG4L 45tjs fqL,ity At,
Date Plade Removed
isEl Removal and/or Held
and/or Address
I= Hold
In
O Date Point of
pi.D Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address •
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home L_1)1Ali ith I, KCLj,Y t5-/
Address
sc,11(a ,A J.,A Iu 1 7a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
ir
Ili` Permission is her by granted to dispose of the human remai s cribed abov s indica - •.
.Date Issued A14- Registrar of Vital Statistics /� i tA,,J
(signatu air
District Number J0/6 Place ndro � _
I certify that the remains of the decedent identified above were disposed gin accordance with this permit on:
Iii p ( 1 Place of Disposition 4.4)4-.r Cyr,,..
Date of Disposition �(((" J� p
2 (address)
Iii
CA
CC (section) -(lot number) (grave number)
0
I Name of Sexton or Perso in Charge of Premises ., L e+
2 ( lease print)
• Signature 71C- - 44—
— Title CIZ" ktxvt
(over)
DOH-1555 (02/2004)