Morris, William NEW YORK STATE DEPARTMENT OF HEALTH ' - 4
Vital Records Section Burial - Transit Permit
Name First Middy Last S
(,c.> ; I I,,4\A,N 3 , v/1/iot`r, S— / 14L-c,.
Date of Death Age If Veteran of U.S. Armed Forces,
`o/ 5-1 a elf War or Dates
of Death �'�' Hospital, Institution or
City111 , own or Village J rh k S r,., Street Address (J e �=
a er of Death Natural se Acc ent Homicide Suicide l termined Pending
W. ❑Circumstances ❑Investigation
ill Medical Certifier Name /9 , Title
!\ 1'GY, Ice-z ink .
Address
]3 ) Lhw c'e., ce j -\(`w Ai l) 3'6 6
Mii Death Certificate Filed District Number Register Number
Town or Village SARATOGA SPRINGS V-
❑Burial Date Cemetery or Cremato
/
❑Entombment Address
['Cremation OA Lem s,4 ) v G``IX)r
Date • (� ! Place Removed
❑Removal and/or Held
and/or Address
Er: Hold
CA
O Date Point of
i Transportation Shipment
C1 by Common Destination
Nii Carrier
El Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Home e A s 44 J re. -'1 .rn ( 4, -L - ea a `t 'it'
gg Address 7
iig Name of Funeral Firm Making isposition or to Whom
Remains are Shipped, If Other than Above
E Address
CC
w
Permission is hereby granted to dispose of the human remains de d a ove a ndi ated.
Date Issued °10/
7l744,3 Registrar of Vital Statistics --t:
(signature)
igi
:iiig District Number t/—v/ Place G, ,^,i C0 SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition/�-/O 13 Place of Disposition �i✓� ✓ ad,4„,,, �s";,
(address)
Ui
VI
EC (section) (lot number) (grave number)
0
o Name of Sexton ir P,rso /harge of Premises Lam/ dlnl 1i4/t d
(please print
141
Signature ./ Ø' Yl S Title atiCrrl4"hdr 37 .
(over)
DOH-1555 (02/2004)