Walsh Jr, Edward ri � 0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section E ---- ' Burial - Transit Permit
1 Name First Middle Last Sex
I Lid idoord eMa.S
tNaW1 fir- Ma(e.
Date of Death Age If Veteran of U.S. Armed?roes,
t (, I 0 7 f tci 3 19,3 War or Dates A//A
�'' Place of Death
-Goy` i • ,' or M b(-eau treat A r r 3 f� K� i ,`1 U�2QU tL1
Manner of Dea�aturat Cause Accident [�Homicide [�Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name . Title
., 1 om tS �a,Ivad(1 . __ �rm
Address LI '
it SouuMain St. `I, Meihanic Ate_ N y. /2 /118'
a Death Certificate Filed District Number Register Number
�:: ►. r M0r-Pju a 1a
Date Ceme ry or Crematory
`: ❑Burial Lo J I `L 1:3 IAA_ Vi cud ' e-m adarti
`' Address
Cremation ,,r` 12c1 Qv1{.eli,5j)un.4 , New L/04_ 12g'-1
Date Place Removed
Removal and/or 1±eld
wr 8 and/or Address
Hold
Date --T-saint of
0 Transportation ! _ j Shipment
a by Common Destination
Carrier
:::Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to d� �1 Registration Number
'1 Name of Funeral Home victrd.�.. j c eraj t O 113Q
Address T
l e .r
`.° Name of Funeral Firm M ing Disposition or to Whom
Remains are Shipped, If Other than Above
Address
?� Permission is hereby granted to dispose of the human re ins described a ye as indicated.
Date Issued W0. Registrar of Vital Statistics qi.
(signature)
1:,.*: Place / i (tnet-t-e-e-e-e— .
District Number ��, 0` `7?
Kwii
I certify that the remains of the decedent identified above were disposed of in cordance with this permit on:
)
2 Date of Disposition tQ 1 l3 I13 Place of Disposition a.,L Crr er w,...
(address)
to
(section) (lo number (grave number)
Name of Sexton or Pers in Charge of PremisesCI
/,, j 3
Z (please print)
10 Signature Title Ci7,cciqrep
(over)
DOH-1555 (9/98)