SMith, Virginia : - big
NEW YORK STATE DEPARTMENT OF HEALTH , ,
Vital Records Section Burial - Transit Permit
Name •,First r r4iddle st SexSe a
l,//f /i?/ cJ /G7/ ` '1 /-eW,e-:a±f
Date of eat Age olvd1/ y& If Veteran of U.S. Armed Forces,
War or Dates
,:. P ac of ath / Hospital, Institution or ?�J kr.
,__City, - r Village c,,E�-�-er Street Address� �,�%1 % ! �,r1Mann of Death .Natural Cause 0 Accident Homicide 0 Suicide �Undetermined ❑Pending
ILI Circumstances Investigation
la Medical Certifier Name/ Title
15 l /07.,-(- 7
dr/ess /
5‘477 Ai1/47?- 9
Death -cate Filed �-� District Number r Register Number
City ow.or Village �Aj fjr/je--J- 1 TW2(5-;2-i- C�
[]Burial Date � /3 Cemeteryat or Crematory
(
❑Entombment Address ��&/! I?'n,e -e (7 /�4�
2remation 6fr,/,....€e__frif-- _z.„7 7- �- 7
Date Place Removed
Z Removal
❑ and/or Held
.,.. and/or Address
=` Hold
0 Date Point of
0" Trans
❑Transportation
Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home�4/-� �j -, [A /" / ,/
Addres ` /
7 i./..c,s--7:er-7c9c- /-7 i--///)_-,P7?
Nam of uneral Firm Making Disposition or to Whom
1• Remains are Shipped, If Other than Above
s Address
1Lt
Permission is hereby granted to dispose of the human -m,ins des•rib=d . • • e as find ated.
•
Date Issued Registrar of Vital Statistics /' / , / ,
(signatur•
District Number,565 Place jru t-, ahtte.A; % '
I certify that the remains of the decedent identified above were disposed of in accordance with this per t on:
lit Date of Disposition Q l 3 l a Place of Disposition U rw`
� nw ,�>�o
(address)
tLI
VI
ilk (section) (lot number) S (grave number)
Ct Name of Sexton or P son in Char e of Premises Aost4r CNKlI
2 (pl ase print)
14
Signature Title cize,m i lt
(over)
DOH-1555 (02/2004)