Hillman, Charles NEW YORK STATE DEPARTMENT OF HEIAILTR
Vital Records Section : . .. :., Burial - Transit Permit
Name F r t i Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
CI— // - e/`� 81
/War or Dates O
Place ofDe th Hospital, Institution or
City, own r Village S c_�. --c 0 ) Street Address /3'6'.V us /Fr- 7
c. Manne Deaths 4: atural Cause Accident Homicide 0 Suicide Undetermined Pending
tit Circumstances Investigation
id Medical Certifier Namee
Co Add
;2- 3-r�s sFa re- ler ? ro%?r l :,u jay, /2cPf °7
im Death ertificate Filed District Number SCE Register Number
City own fir Village ,Sc--h f- tei t&„ I
>' ❑Burial Date Ceme or Crematory
C/— // — 2_d/3 j,'eveii/e., G�..� -.A 1 eY y
❑Entombment Address 2
iiIRCremation u e.AJ..5 J o-v�Y Nye , i p� g C?
Date ( Place Removed
z Removal and/or Held
• ❑and/or
Address�
J
Hold
0 Date Point of
EL El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ,� Registration Number
Name of Funeral Home &ct)Ahit 4.,.1°(el, ri,u.,e,,s/ /v'00-a ar-5 77
iNi Address ik K -_ NY. / f 7 4
iim Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
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w
` Permission is hereby granted to dispose of the human aiinnsAdescribed above as vindicated.
Date Issued p j_1/- jj Registrar of Vital Statistics �J ,es ,�-36-A-c.k-
(signature)
District Number I Place at644 ,,44 i_y.L" ej
I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
Z
t1E Date of Disposition i-lki-13 Place of Disposition 04(ka Cr+n•etor:DP-I
2 (address)
Ul
Mt
CC (section) , (lot number) ("`' (grave number)
CI Name of Sexton or Person in Charg of Premises of 4
(please print)
Signature Lib" Title CULKAX
(over)
DOH-1555 (02/2004)