Waite, Ralph N t337
NEW YORK STATE DEPARTMENT OF HEALTH � Burial _ Transit Permit
Vital Records Sectiona
Name, ;first L Middle Last Sex
/
Date of Death Age If Veteran of U.S. Armed Forces,
( 7- Ja 7 . .._ War or Dates
} Place of Death I Hospital. Institution or Q/
CityCfowr)or Village G r-e eiJoi Street Address I (P l lQ 1)1( / c)
Manner of Death Natural Cause ❑Accident �Homicide Suicide t l Undetermined Pending
Circumstances Investigation
Medical CertifiL , Name Title
I Addres
Sa r'O4 )q a.
-
Death C rtificate Filersn i r JS 1 istrict Number Register Number
City, own r Village (5r Yn r�,� S$1 g 11
Date C etery or rematory
El Burial 7 � f� 1 >n 1 e-1 t, � _C&+O ry
Address _..�
Za Cremations D f
Date Place Removed
O❑Removal and/or Held
and/or Address
1-1
a Hold
G7 Date Point of
2 Q Transportation Shipment
Ls by Common Destination
Carrier
Disinterment Date Cemetery Address -_
Reinterment Date Cemetery Address
"'' Permit Issued to (('�� Registration Number
Name of Funeral Home Z ru i)Cc 1 I ry_ra l_. A I nc _ (JCa, I
i
-.::: c 'el a)wrch___St, i_a_loe_ Lu_z -r-nzi 1.1y iova(.0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission is hereby/granted to dispose of the human remains described
above as indicated.
Date Issued (2f1 hereby/ Registrar of Vital Statistics "I-✓)rL --
I /(sign re)
District Number 4651
Place ---Gr,Jn Q5 C.J C d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 113111 Place of Disposition ?imAktu CruhAorior-
6 (address)
W
tf?
CC (section) number) (grave number)
0 Name of Sexton or Person in Charge f Premises A:41,o4t
sC..it
g (please print)
IU Signature AL Title CitemprTion,
DOH-1555 (10/89) p. 1 of 2 VS-61