Smith, Burt NEW YORK STATE DEPARTMENT OF HEALT,,H _ ay `
Vital Records Section Burial - Transit ermit
Name First Mi dle Last Sex
Date of Death Age • If Veteran of U.S. Armed FForces,
c21 � I ) ' L� d War or Dates / 7-5/ - /fSr V
14: Place of Death Hospital, Institution or
M. City, Town or Village c ( �4 0-iv t Street Address q ii J j tl(i- `'E1
ci Manner of Death Undetermined Pending
.Natural Cause Accident �Homicide Suicide
tti Circumstances Investigation
Ail Medical Certifier me Ti
� 0 hc L, ScL rr tle/y
1
Address
€ . o rlr;,„ 10-46-- gedi ti ecd 7Z. 0 c ‘i-&:1 t JcL j I1-5-.9d
Death Certificate Filed District Number + Register Number
City, Town or Village .�41._cG�/j 1 D(3 _5
],ii❑Burial Date Cpcitetery or Crematory
❑Entombment Address
m [Cremation 92-P Ai-5 -4 GI r,'
Date Place Removed
Z. Removal and/or Held
and/or
r, Address F
t
Hold
Date Point of
t)" Transportation Shipment
. by Common Destination
Carrier
n Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Xii Name of Funeral Home , 4, - 1 tler* I r. ' s 19
Address
.. Cif t—evilt e_. '. 7i)
;>> Name of Funeral Firm Making Dispositiofi or to Whom
' Remains are Shipped, If Other than Above
•
2 Address
it
t E
t Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued O le'ilpt`913 Registrar of Vital Statistics �c rit.ie:„...,:ik -.._C C .'L.,��.{.
(st nature)
District Number `^ Place5.-' ‘
,,,,: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
1fl Date of Disposition gh,3)M Place of Disposition Z.10iiv C•cira--
2 (address)
t'
tt _
(section) (lot n mber) C (grave number)
ti Name of Sexton or Perso in Charge o Premises r' �ti
Z (pl ase print)
ill
Signature Title c1 enk-toot
(over)
DOH-1555 (02/2004)