VanOnden, Arthur tt
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NEW YORK STATE DEPARTMENT OF HEALTH . ii 3 °Vital Records Section Burial - Transit Permit
Name First Middle Last n
/79 T-/1 U,2 tJ/L L//9./'91,43,A) /U J if2 65', or
Date of Deatty Age If Veteran of U.S.Armed Forces,
toi,jam/ 2_ War or tes f33 &k 40w,.) bears
of Death Hospit Institution_)
C gown or Village I,j F,�-1„&5 Street Address /mr RAJ 653 W[S it-lef(Wa,
Wanner of Death EtNatural Cause 0 Accident 0 Homicide Ei Suicide ri Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name (, Title
Address
/20 1,-)e-ru/Lc3--,) -)7-, Ote-,J_J re-Lcs
h Certificate Filed District Number I�e9 is� er umb r
City own or Village (.e.3 S F81.LS v7 0
Burial Date Cemetery Crematory 0 (1/61-3&' /cP1/Z / i�[c
❑Entombment Address Air
remation
'� � U�'I�bv�. � � u 6�`.JS e
Date Place Removed U�
Removal and/or Held /'
and/or Address
N Hold
in
Date Point of
0 Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home t-i 0,1 nu 8 ,.fScaer r .r cal r-c_ 3 1 13O
s Address
Name of Funeral Firm Making Disposition or to Whom
a Remains are Shipped, If Other than Above
Address
tr
lU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/ a r 2, Registrar of Vital Statistics c&A n 2,(A)
(signatu )
District Number 'd/ Place 67e/2i, //s, / / 8-0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4' V Cif ltt Date of Disposition t,to I ill Place of Disposition ,M. rep,, Ot•iuw,
2 (address)
w
0
IC (section) / (lot number) (grave number)
S11-
Name of Sexton or Per on in Charg of Premises ri 5�fr ;#4
/ (please print)
lt! Signature L Title
(over)
DOH-1555 (02/2004)