Ladd, David NEW YORK STATE DEPARTMENT OF HEALTH i- , •N
Vital Records Section Burial - Transit Permit
Name First Mid e Last L i , Sex
Date of Death Age If Veteran of U.S. Armed Forces,
/ I 3 '-4 War or Dates
Pla off Death Hospital, Institution or ` j��
ity own or Village 6L�. c`'ats� Street Address (� 1—...a.L. ORO
• nner of Death Natural Cause Accident Homicide Suicide ❑Undetermined Pending
t ® Circumstances Investigation
iti• Medical Certifier Name Title
Address:::::: lb`D `1Peti'‹ Yt .�-z� i(� A, y a_
c 0 i
iiim Death Certificate Filed Disfr 6�ict Number Register Number
Niiii ity, own or Village Ca/�.n Q ( Z 1
urial Date Cemetery Crematory
iiiii 0 Entombment Address V//
sss >[premation vA.t..e' �s j / M e 7.2 f/C
.�r •
Date. Place Removed
❑4 Removal and/or Held
and/or Address
f
"` Hold
0 Date Point of
t"0 Transportation Shipment
Cs by Common Destination
Carrier
El Disinterment Date Cemetery Address
iiiEiQ Reinterment Date Cemetery Address
nii
>_ Permit Issued to Registration Number
Name of Funeral Home �„.>4,4 rt irvt �++-s, .,mac 00 i'Y"g
Address
--7 5kef—k— A-p-t K.:-:,,,,,vt7L--------Ais tr ./:;4t'QD,
mii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cr.
w
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued G/ G 7r5 Registrar of Vital Statistics W k.")
(signature)
District Number 5 6 01 Place 6 (sz/„-S k `5
Ai I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iii Date of Disposition 10(7 I(3 Place of Disposition 'r c-it'tOft -
2 (address)
iii
I (section) Ifc (lot umber) (grave number)
Name of Sexton or Perso in Charge of P mises r.S'� •i �n�eN-
(•ease print)
ill Signature `t.• Title CC/Mirk-
(over)
DOH-1555 (02/2004)