Hamblin, Virginia t II it
NEW YORK STATE DEPARTMENT OF HEALTH- ' ' 10
Vital Records Section B rial - Transit Permit
Name First Middle Las ( Sex
\l i r-a o li CA 1 ttarn.bl;n c
Date of Death Age ' Veteran of U.S. Armed Forces,
i2-,13 �Zpl.3 gr) If War or Dates
I-a Place of Death i Hospital, Institution or
Cititiy own r Village �(`y(� l r trc� Street Address Ic- k\\)b D4 KhAr5yY� F-ball
II Manner of1)eath Vel Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
tui Medical Certifier Name Title
— —_ E'k e\ Sp,rye\\�.. fik n V C
Address (`� ((��-� .. 11 -� j
`\ CO / L D \ �VtC'ED t.( y tv 1 -a 1 —_
Death Certificate Filed j District Num J r egist umber
City, Town or Village 7 �
❑Burial Date I Cemetery or Crematory� )
❑Entombment '� Pit )2b) e inf_ Vie U3 Crkrna-i-cry-y
Address �
Cremation Q\ it to ►r ) Ai Dti
Date J i Place Removed
gr-ia Removal j and/or Held
and/or Address
(1) Hold
0 Date j Point of
NQ Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home CirCkr c, 7, iSc .e Rnc r a.1 `i()riAL 1 - 01 130
Address
`1 LaiGyc }I A. , (..s>t_l,ccr>S1ou �c a- 12 `S
ry , tic v,1 U`--\
Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above _-
2 Address
U11
tL Permission is hereby anted to dispose of the human ains described above as indicated.
Date Issued Registrar of Vital Statistic - _ —
,�—J 1 (signature
District Number 7. Place At i
#- I certify that the remains of the decedent identified ove were disposed of u p accordance with this permit on:
WDate of Disposition j -dd-13 Place of Disposition gitaL C rt sar“--
2 I (address)
ILI
VI 1
CC (section) I (I number) (grave number)
its Name of Sexton or Person in Charge of remises 5
4 _ _ I Ill S[k�
(pleas print) ,
Signature Title 612,60111.7D4
(over)
DOH-1555 (02/2004)