Bombard, Martha NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section i Burial - Transit Permit
IN Name ,P,irt
ci-4k C-1 I�ct6. 6�� ,Sex
to of DeathIf�Veteran of U.S. Armed Forces,
62i 0 k 0 War or Dates
Place ath Hospital, Institution or
Ci ,Town r Village_ Street Address
Man eath Natural Cause 0cci ent El Homicide 0 Suicide nUndetermined ❑Pending
Circumstances Investigation
tii Medical Certifier Name Title
i aezV Udry (Z. V lt�z ham.,
Address
tit 1 CQ4t4 Rd&A , azee+-(tiu.c N i( 1),...Qe)4
De 'icate Filed District Number Register Number
} Ci , Town o Village ( C "� + 1
Date Cemetery or Crematory
❑Burial 1,40,y Zq i 2ok.Z PZh,e V;e.....) C.,re - 1. •
Address
Cremation cwa ,,, ac ad , &tee 6,r th,4ry1 t Ili`( 12eo 4, .
g . Date Place Rerhoved
0❑Removal J and/or Held
ti and/or Address
Hold .
0 Date Point of
it0 Transportation Shipment '
a by Common Destination
Carrier
.:: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
`.. Name of Funeral Home C Fyn LeCUn) fo L. t f , �
+t U � Q
ki Address
6 niksTEJ S T Q P54 ci J - 1-1 . 1213,
in Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
ill Address '
aii Permission is hereb?f granted to dispose of the human remans described ab ye as indicated.
Date IssuedSl c�C) I a,Registrar of Vital Statistics � -}CA---, 6 rLk¢____.
,
(signature)
iiiiiii
District Number C -) Place S •
I certify that the remains of the decedent identified above were disposed of in acco6lan with this permit on:
.I
Date of Disposition ri3I lL Place of Disposition gssi)u1,, Crul..tor,��
2 (address)
LU .
U)
CC (section) II (lot number) (grave number)
GName of Sexton or Person in Charge of remises Chey{'ap(..r •4-i f-
Z (please print) i
Signatu?e Title ctf n 't
(over)
DOH-1555 (9/98)