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Skellie, John
NEW YORK STATE DEPARTMENT OF HEALTH* ti 111 Vital Records Section Burial - Transit Permit Name First , Middle Last Sex JOrIn Date of Death Age If Veteran of U.S.Armed Forces, 1\j act 1 ZL3 13 (-9 oZ War or Dates Place f Death Hospital, Institution or ,Town Village 1-,Y1e pvccks aan4- Street Address C'(1ef — VtJ OOc S Manner of Death El Natural Cause Accident ❑Homicide u Suicide ❑Undetermined Pending Circumstances Investigation Medical Certifier Name Title tbina1C0 )bra1Adl,l�.S (`©saline r Address . )OX 4 3 i Lit Y-) P\eScc n Ir, N'( 1 2)o CO Death icate Filed District Number Register Number • CI Town Vlla�e Lekl�i g.4u�- a_ n £. es Date ` Cemetery or Crematory >:::LJ Burial \\ \ a l 2.-a)3 p;ngV;eu3 Cremakor Address 1 ®,Cremation ax 4Q v 15YJt (a i 2- CAL+ Date JJ Place Removed O❑Removal and/or Held and/or Address Hold 0 Date Point of Q Transportation Shipment 3 by Common Destination Carrier Date _ Cemetery Address El Disinterment 0 Reinterment Date Cemetery Address iiiPermit Issued to �t ` Registration Number ' Name of Funeral Home I' nard O' 'Baker Furierai Home' 0110 Address. Ir, Caul -e of. , OIA LE"bund , e w Mork- Igg01 ` Name of Funeral Firm Making Disposition or to Whom 'w Remains are Shipped, If Other than Above - Address m Permission is herebygranted to disposeof the human remains described above as indicated. 4 Date Issued J/• .Q ,/3 Registrar of Vital Statistics (,40r,� -Tel 0.1-f.` (, - •- Q (signature)" District Number oZ D. 5 Place wI/ P (_,..a-s I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iDate of Disposition_ I 1�-`0 Place of Disposition �S,i�tJ� �"�toe,,_ (address) f� ca cc (section) (lot ) ( (gave number) 0 Name of Sexton or Person in harge of remises r, J/„N f i' (please print) Signature Title rGroTAZ • (over) DOH-1555 (9/98)