St. John Sr, William '65--
NEW YORK STATE DEPARTMENT OF HEALTH! Burial - Transit Permit
Vital Records Section
"` Name First Middle Last Sex
i ,\Vc. (c'VL� S\-'. ... � Sc 1 "
Vi Date of eat A e If Veteran of U.S. Armed Forces,
>K. peat.)
�� War or Dates 1°14c.7-6 6ci---f- (
Place of Death Hospital, Institution or ,t
b City, Town or Village COO-I n Street Address i1 ii°, ¢} Lr Q'
rManner of Death 2 Natural Cause Accident Homicide Suicide Undetermined Pending
ilCircumstances Investigation
Medical Certifier Name C.� Title M
`�. 1 Od R e 1 1 .- c\ I )
< . Address 3 i Mf 3c,-,,,'t. ,X N I ro 4,
r. Death Certificate Filed District Number Register Number
i-!:: City, Town or Village
n t� Cugletery or Crematory I
l?=. ❑Burial Date O if 1 I � �3 r I \ c - Cr '�.`10
Address
:::. ®Cremation �v c.,� a-kce tA.4',..9 t d,'
Date Place Removed 0
❑Removal and/or Held
'� and/or Address
• Hold
6 Date Point of
A'Q Transportation Shipment
q by Common Destination
Carrier _
Disinterment Date Cemetery Address
::::: Reinterment Date Cemetery Address
Permit Issued to � Registration Number
g. Name of Funeral Home .Jf✓t�YhD {-C art C16' A(- 004 LiS
IN Address I
S ,� . _
Ai..: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
SR
Permission is hereby granted to dispose of the human remain ribed abo as indicated.
Date Issued 2-/?-/ 3 Registrar of Vital Statistics ° .
_- (signatut
''`x s 4
District Number ��'S3 Place ,6.,,,
iii I certify that the remains of the decedent identified above were disposed of iinn accordance with this permit on:
• Date of Disposition 2-Zo-t16 Place of Disposition ZIilAw 64'4tw-
(address)
• (section) (lac number (grave number)
.a� Name of Sexton or Person in Charge of Premises !hiVta s rn>�
g (please print)
Signature Title Citetm AVE.
(over)
DOH-1555 (9/98)