Galusha, Dakoda NEW YORK STATE DEPARTMENT OF HEALTH If SS I.
Vital Records Section Burial - Transit Permit
Name First �`�� __Middle /'' Last Sex
_,,� (�<Lu S k S
Date of Death / Age If Veteran of U.S. Armed Forces,
/ i 7/ 2.0/3 d 5 War or Dates
}- Place of Death Hospital, Institution or
Ci As own . Village 1-1,A).-e-a. Street Address 534 A-—1 114-1-\ ilk
Minn - :-ath N Natural Cause Accident Eil Homicide 0 Suicide Undetermined Pending
ILI Circumstances Investigation
lij Medical Certifier Nam5 Title
QLss .tit
Addre s
1' w�rMtiv 6. ,., tea,-, Nr Iagot
Deat ate Filed Distj .
rict Number Register Number
Cit ,,,Tow Village k«A Li-SS 6.
❑Burial Date / Cemetery or Cremfv
y
❑Entombment i/ �`o 0i3 .c•..• �r .� ,-�-�
Address
Ai[ Cremation C ue.c, ..,,r 1m-.4-9 r'oE2
Date j 11- Removed
Z❑Removal 1Place
and/or Held
and/or Address
h Hold
0 Date Point of
0 Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to — _ Registration Number
Name of Funeral Ho n ,,,,arc. „it/'� ( (-to,.,.7 ,).4Z a e 71-fir
Address
thLFM-� AV{ Wr- M / ag_L
Name of Funeral Firm Making Disposition or to Whom"
Remains are Shipped, If Other than Above
Address
CC
W.
'` Permission is hereby granted to dispose of the human rem ' s described above as indicate
i Date Issued q 1 g . )3 Registrar of Vital Statistics ,c=�y C:V-4
(signature)
District Number L/3 Place _ J���`'"`v' l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition 'f 113 B Place of Disposition ,j,. .
a� �^SV�"' nn.er�r�....
11 (address)
Ul
c (section) Aot number) (grave number)
01
ci Name of Sexton or Person in Charge of Premises r� '', S^dlr
2 �/ (please print)
Signaturetii ✓Gi (� TitleC3-t-�� C ��� �tfiMlttut
(` 4 (over)
DOH-1555 (02/2004)