Ramsey, Warren NEW YORK STATE DEPARTMENT OF HEALTH ' l
Vital Records Section Burial - Transit Permit
gn Name First Middle kast Se
rs 3 �G,�r<° ./�
Y.- �Se �'1
<{Jy Date of De h Age If Veteran of U.S. Armed Force
palate 1)3 '1 a War or Dates L.) r kd l s- 1 . `Aa
Place of Death Hospital, Institution or
;'�. City, Town or Village SCocr� . S \ � ASS Street Address -se, � � e i 4s
Manner of Death
i tu ®Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
>'= Address
Death Certificate Filed District Number 'Register umber
is City, Town or Village 0«
Date la 1 a3 j i� emetery,or Crematory
'.. ❑Burial I S"2 V lv.--J C-� c- '-
6
Address 1
: ' glCremation Address"
Qc :A �•eek-,>\oos� kt,_Y'L (a$Ot--k
Date Place Removed
2 Z❑Removal and/or Held
and/or Address
ri Hold
!C3 Date Point of
2 Q Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �'1 , ` Registration Number
= 5I Name of Funeral Home Je4nS�art �v�rc.,\ t^1 4. �jpL1(-Ag
:! Address n t a
cpa
, �' Name of Funeral Firm Making Disposition or to Whom '
Remains are Shipped, If Other than Above
Address
0
Permission is he eby ranted to dispose of the human rema esc 'bed?ve s indica ed.
f;.%<r� Date Issued t2 Z� (� Registrar of Vital Statistics
I SARATOGA O )
aDistrict Number L(5(1 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1114-13 Place of Disposition -Pnp V it,.., ( -tonn,..
2 (address)
W
f)
(section) (lotnum ) (grave number)
g Name of Sexton or Person in Charge of Premises << 4
g lik _ (please print)
Signature Title CAr w1ffio C
(over)
DOH-1555 (9/98)