Wheaton, Gregory NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Vital Records Section
Name First Mi die Last Sex
�re n� l he-a. c_ M , L e,
Date of Death Li
If Veteran of U.S. Armed Forces,
// ! I 1 S--- 1 War or Dates
8:z_P-Ia,c of Death Hospital, Institution or
City, Town or Village,C,r-‘,4-v 'k_ .�,r;k z__Street Address �r... E-4.>S -
iManner of Death Natural Ci(ise �/ccint Homicide Suicide U etermined �❑Pending
Circumstances Investigation
u Medical Certifier Na 1 Title
L ..,AA e tr,z� M f�
Address n Af
Death Certificate File c� District Number Register Number
Cit Town or Village SARAT®GASP INGS .y
j)k
OBuriai I Date Cemetery or Cre tort' h
r/ a0i3 - le v c -° '/\c;im.e-�,
Entombment Addressf� �'J
in EtCremation LXL&c_ e „ S Lt r H
Date / Place Removed
�I
Removal and/or Held
12❑and/or
t Address;;
Hold
0 Date Point of
85 Q Transportation Shipment
C by Common Destination
Carrier •
❑Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to _ Registration Nu ber
Name of Funeral Home0-2,.S M c 1 H 1„� 4.30 4
Address r5t,, ,MF^ .4.. C r. tip. . /`J . ` „, 1 a2 b _ Z
/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
al
fl Permission is ere y granted to dispose of the human remains des - a ye a`s dic ted.
Date Issued 7 31 /3 Registrar of Vital Statistics A/N,N ! .
(signature)
District Number 44.5-0 Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
dd
illDate of Disposition I1 I 1 i"N Place of Disposition ;,,�U�.•�, Cat of w�,,,
2 (address)
Ili
til
CC (section) i.(lot number) (grave number)
Name of Sexton or Perso,f n Charge of remises c, S t
2 (p ase print)
Signature / Title etW t ip row
(over)
DOH-1555 (02/2004)