Mann, David ` fi 11
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit ermit
Vital Records Section
me First Middle Last Sex
M M
Date of Death Age If Veteran'of S. Armed Forces. a �-
3-ZipL 3 Z. 1 War or Dates f'b
'f , Place of Death ; Hospital. Institutiopr
i y,Town or Village rn- 3&cS , Street Address GS Q
fl Manner_ of Death Natural"'" Cause ❑Acctnt 0 Homicide 0 Suicide Undetermined ri Pending
11 Circumstances Investigation
-W Medical Certifier ame Title
Address f
Y___
Death Certificate File District Number 1 Register Number
_`�t , Town or Village G- ,k 1 1 h c �-J� `i _
Date 5 �J '.. metetry or Crem tory
EllBurial 3 2 4- 13 11 re-Y 1 P tD ( x JNI Q+Q -
Address
TACremations U V
Date -'� /Place Removed
Removal and/or Held
and/or
-I- Address
tA� Hold
0 ' Date Point of 1
ma' Transportation Shipment
13 by Common Destination
Carrier
Disinterment ' Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1TAA.le rtc- 0 per( I
Address ` -1- b (',h 3t Niy i s tko ___.
Name of Funeral Firm Making Disposition osition or to Whom
Remains are Shipped. If Other than Above
Address -
Permission is h reb granted to dispose of the human remains described abo a as indicate .
Date Issued 2L (', Registrar of Vital Statistics e
SARATOGAQfv‘
'' District Number ySv( Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
W Date of Disposition 3-76-t Place of Disposition -s0K••) Cr't f t i.r.
(address)
iti
(/)
GIX (section) A,lottiLnLmber)s:44 (grave number)
Name of Sexton or Person in Charge of P emises
z (please print)
W Signature �- Title CV__
DOH-1555 (10/89) p. 1 of 2 VS-61