Hermance, Richard it
NEW YORK STATE DEPARTMENT OF HEALTH t N, "i3
Vital Records Section Burial - Transit Permit
Name First -Middle Last Se
1 f I CH j ri/.J c1l
I Date of Death Age If,
Veteran
of U.S. Armed Forces.
i I
/iq �73
i,:r or Dat_
P iu, n of l Stifi:Tv , or
Q 1—I Pl'1' ath�1L[�
r�
450-4
p Manner of DeatIXNiuiatural Cause [ 1 Accid It [P Homicide fl Suicide 7 Undetermined I 1 Pending
0Ciicun1starce s Investigation
W Medical Certifier Name...1, ft
Title
^honC 0� IHerr *cif ;earl
Address T
319 Qaq ed. £Lee,ns wif ,WY 12Xoif
Death uticate Fuec �D� trici Ntirnbei Re inter Number
Ct y T 1vVI i vll:C,1.,_- Q 0 ASFJ �C �a
' I� Date
l I Burial Cemetery •
_ -
li/2Zf/3 l,J V► Li '3
i mbment�U r'to Address
' -�.,I ati v i Q 0 n/e_L''ti— l rry
243 C (-) iJ s 12 imi7
'fir--, P ra m,- , i
Date Place Removed
and or Address
!I.— Hn,1d1
V?'
101 Date Point of
u z4i,srJ,,i taiiol i
0i by Common Destination
Carrie!
I�C'I
Date
Disinterment Cemetery Address
Cemetery Address
l
Reinterment Date
I Permit Issued to • Registration Number
I Address
Q�eell�ber�, 114
Name of Funeral Firm Making Disposition or to Whom
r • ;i„ii :o a:c J:il f,j.�c... I: Vt :t :I: t � ,vvC
'2' Address
ua
,.••. . t. is ir..,..,io i is ..0reiJ'y' granted o .... i{,:e;: ..:ii ,-iui-r, . .ir.., ......,,..,i1..e di-,.-...-:.,,..,.., ,....� ...:—.. c teci.
i
1 Date Issued Lit l 3 Registrar of Vital Statistics- �� C
��,:,�.L a I?,0i-^�
District Number Place 1 o � ��L
-ram
�1 ,.:,'.,:y ilia Li IC: Iel l:ri:rib �r liicJ .:ct.,:rUCi It 0U,2iiltlk - auv,,C vv:;i ";DrrJJ,,,I ** IU- -J uaiwr✓ ':ttI ui1J IJI,iiHIL Oil.
Zi
WI Date of Disposition LJ-Z'y-L5 Place of Disposition
ti aa^res ,
Imo' ,
mo'
�1 ��:_,.,
mil' Name of S4XTori or Person 1 Charr nt Prp o sr,s IL Spiriall
Li' Signature Title � ��
over
CdH.1 " 1,02,9004'