Sherman Jr, Owen NEW YORK STATE DEPARTMENT OF HEALTH ' • n
Vital Records Section Burial - Transit Permit
Name First ,, r Middle Last �i2 SiAC��
Ot.J 61--J w I L ) -J1 H bv`.i'-14, J V/
Date of Death I Age If Veteran of U.S. Armed F rces,
24111.1 7 7 War or Dates AU 4
Plac ath Ho ital nstitutio or , t )
Ci , Tow Village 2 p L'� (Street Ad r re �es /V J V 1,an..f ai,�'T Pe
a Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide ❑Undetermined 0 Pending
la Circumstances Investigation
in Medical Certifier Na Title
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Deat ificate Filed District Number Register Number
Cit Tow r Village � d 1 TMJ
❑BUflaI Date l Cemetery or Cremato \
Entombment /2 O/l a i�J 6r U/ L-
Address c.ThAr
rcrnat:cr (2. aue.a„Jsauvt7 )2-ed, 9/
Date Place Removed
Z Removal and/or Held
2 and/or
I Address
fa
Hold
0 Date Point of
6❑Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ainr
Registration Number
Name of Funeral Home /1//97A5 I2.61.6.L JV,Jsz, 0/ /c
Address
// COF19c17771 ‘ Q () -1.ssc
/(71 12 e 0 y
Name of Funeral Firm M in Disposition or to Whom / /
- Remains are Shipped, If Other than Above
2 Address
C
t:
1:1` Permission is hereby granted to dis ose of the human ran7ils scribed abov i dicated.
Date Issued 040-.a)/3 Regis rar oNtalStatistics _ —---� --�_�
(signature)
al(--AC
District Number ip ca Placeiey_tee2/(...)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition Z.-1I-13 Place of Disposition tAI'tu..) 6 1r;,,,v
2 (address)
lit
Ul
CC (section) � v(lot number (grave number)
Q
Name of Sexton or Person in Charge of Premises fi
, � w
z ( lease print)
iii Signature Title C *f bit'
(over)
DOH-1555 (02/2004)