Pakes, Dennis NEW YORK STATE DEPARTMENT OF HEALTH F .4
Vital Records Section Burial - Transit permit
is Name First Middle t.a�t Sex
,D,6.t)4.95 AL�..cd S H6 Lr
<t Date of Death - Age if-Veteran of-U.S.Armed Forces, ,
FM '/' 7 ?ai
7S War or Dates
6Place of Death Hospital, Institution or i{0f}t�,vys a_Sg- c9J /p,E,
City,Town or Village 6&9- 0 iLLE , .- Street Address
Manner of Death rn Natural Cause O Accident O Homicide El Suicide O Undetermined . ,Q Pending
Circumstances investigation
Medical Certifier Name �-- Title _
''. tth )/r ► J eosscj k Q-
Address
-A,7 6�4. : ems$ . �2d 3 l
4a Death Certificate Filed District Number. . - . Regis umber
:>:k: City,Town or Village !1-4.0tJ 1 z- Sri 6(;� (;`j
.24 OBurial Date Cgnetery or Crematory
�itO Eribmtxnent
�' Addr s - " a
"'' Cre�nation WC/ L/
'•A'- Date Place Removed _ .
ElRemoval and/or Held
oir and/or ----
--is " Hold Address
Date Point of
' Transportation
in Li P Shipment
n by Common Destination
s>, Carver
3 Disinterment Date Cemetery Address
it0 Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home ��t) 9 /5/ C ieicR`*--
Address •
-1(-7 /tP/
€€µ' Name of Funeral Finn Making Disposition or to Whomtig /
: 9 P
i Remains are Shipped, If Other than Above
OE Addressir
Ni Permission is hereby granted to dispose of the human remains described above as indicated.
it Date Issued 44/j( )a 3 Registrar of Vital Statistics c` e;
? 4 •• (signature)
"= District Number 6-�"(�L Place
mi d ref Csr�ry; I1�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
^ Date of Disposition q-JZ13 Place of Disposition Z,LLJ (_cv,.c-40r01 .
Or (address)
rcZ
. (section) (tot number) (grave number)
Name of Sexton or Pe on in Charge of Premises A r.i101� .�1,14'it
/ (please print)
1..7 Signature Title C-(�F_ iTOQ..
(over)
DOH-1555 (02/2004)