Smith, Wenona NEW YORK STATE DEPARTMENT OF HEALTH s I, lit --I
Vice Records Section Burial - Transit Permit
Name First antv v e rlor o. Mg
. 'r t h F
a Date of Death 111201 3 Age If Veteran of U.S.Armed Forces,
g War or Dates
Ply Tow r illage F-I . Ed ward titer ess Fi-. i-luct So n _
Warmer of Death 14 Natural Cause ❑Accident Q Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
Medic`C er Name L Q i l ( TitleMP
Address 1
Death c Filed �i` Ed ld District Number Register
� owi n HVillge ���
❑Burial Date $'I q 12_013 €iematory IT 1
::Cremation Address l�Gt � �d f � �15 r J0 7 1 c o`1
Date Place Removed
AG ri
AG Removal and/or Held
i and/or Address
a Hold
Date Point of
O Q Transportation 1 Shipment
8 by Common Destination
Carrier
:: ❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to t J Registration Number
`Name of Funeral Home l Ord b. esker Fw ecrz� nomc_ Of 1'0
'. Address Ii LQr tt �'C-d r 1Ue.(A) fU k
Name of Funeral Firm Making Disposition or to Whom
. : Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human ins described abov as indicated.
Date Issued /g L Registrar of Vidal Statis
' nature)
District Number �� Place 4fZ2 _J
I certify that the remains of the decedent identified ve were disposed of in accordance with this permit on:
Date of Disposition gl LI I I3 Place of Disposition � �v r r5a r
(address) 'f
tLI
al
Sr (section) /J(lot n ber) C' (grave number)
AName of Sexton or Pers in Charge f Premises ' it v I,fr
g (please print)
1 Signature Title cI gvcTds.
(over)
DOH-1555 (9/98)