Streever, William NEW YORK STATE DEPARTMENT OF HEALTH #
Vital Records Section Burial • Transit P ermit
Y Name First Middle Last Sex
� 1 I i 0 a eeVer•
iii Date of Death Age If Veteran of U.S.Armed Forces,
e! Z 3 1 .3 ()V War or Dates \ tS - 10
Place of Death
?.. Hospital, Institution or
i City, r o Village Ikee s\\Url Street Address SA-p,Y\�„� P�v\YS' ,,� `1=10q'te
:K:, Manner of Death b7 Natural Cause Q Accident Q Homicide Suicide Q Undetermined ending---
M. Circumstances Investigation
Medical Certifier Name Title
Rbalyn SoCoio Ml�
Address
S Z srtvir awl 44-we rw-L Q•,-aax1Sbw eNt i A. y i air+
A. Death Certificate Filed District Number i
Re isterfNumber
Cit C towt r Village (ueei\Sb th Y` .1 -
Date Cemetery or Crematory
`.: ❑Burial al 1 02- 1 2014 Pi(NC C V;C u: C.re t'ea -o
Address
.. LJ Cremation Qu.kkil S\ou rL i N 12W}y
Date P e Removed
A n Removal , and/or Held
and/or _���...
Address
1.{ Hold
d I Date __.._....:_ fi Point of
` 1 Transportation j Shipment
a� by Common [ Destination
Carrier
Date Cemetery Address
0 Disinterment
Date Cemetery Address
Permit Issued to Registration Number
II
\ nafd , fD -L e r FL�.nera 1
Name of Funeral Home I , b 10
Address ' 1 La'aye. t e S-f. , Q ,u°crl r �.,{ �1�`{ o�
' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.. Address
04.1 Permission is hereby granted to dispose of the human remains describeabove as indicated.
Date issued 1 1 2-1 2D1 Li. Registrar of Vital Statistics�_. Q �J cU/L 1
(signature)
S . ,,
District NumberC9 STh Place 1 d O "C n (, ,,,_C
I certify that the remains of the decedent identified above were disposed of in accor a with this permit on:
J Date of Disposition I it Jig Place of Disposition e r,,�.
(address)
(section) (lot number) (grave number)
Name of Sexton or Perso -n Charge of Premises ir,iilviri
(please print)
Signature Title CIYE#A-149
(over)
DOH-1555 (9/98)