Ernest, Nelson ff /1 4")
NEW YORK STATE DEPARTMENT OF HEALTH •!, ,
Vital Records Section B u r i a I - Transit Permit
Fir
st,}I icil e S051/14
.,.,...s.:,' A ,- 1 M
56/)) \.1 .. .) La g:,e..?0.147 s7
Date of Dens__ Age i 2/ If Veteran of U.S. Armedfor,ces,
- /6 -c)a 3 La 7 War or Dates / 6-109 - /q /14 Place of Death v/4 , , i Hospital, Institution or
a City, Town or Village /-1 g k ii.2.-- 0-17 - Street Address
Manner of Death
Lir-I Natural Cause El Accident E]Homicide E Suicide ri Undetermined ri Pending
'Circumstances '-'-'Investigation
hi Medical Certifier Name P ( e r Title o ,rcz.),s
&Ik c...„
iN Address
....,
..„..„ Nr Y1 S4- kleters-r S ttri-t_ dt/P /2E65—
Death Certificate Filed j District Number Vegiste Number---
4 --
11 City, Town or Village A ke_ 14)2..e,etX ,z-.- (a.5-Z ,,,,.-!_•.._ 3
.....
,..._, Date Cemejwy or Crematory
i /.
L Burial 5--- i‘— /3 rf n e LAe, cu C._ res----446rtt_
•-
Address
5.60.Cremation -2-- / 6?Otak2/- 0(A6,e(As bc_cr- .... A)
,
Date Place Removed V
Removal and/or Held
and/or Address
1:-- Hold
0 Date Point of
(I%El Transportation Shipment
5 by Common Destination
Carrier
.•.•. ,—, Date Cemetery Address
ll Disinterment
.•.•.
.•.•.
Date Cemetery Address
El Reinterment
....
Permit Issued to /- Registration Number
il Name of Funeral Home 4,(-40° pc.i.,5 c c t,'I 0-4.-e._ AA_ vverC1..,A, I-42 00
:iEg Address
W 2 kklek 0 re 4 oe , 5;re-cf-o2 Sp - Ali' 1 2-te6s .
a Name of Funeral Firm Making Dispodition or to Whom
.... Remains are Shipped, If Other than Above
Address
-i-:
.,.::.
gi Permission is hereby granted to dispose of the human e ains des ibed above s"ndicated.
, iilf Date Issueclff:- L.c-c)c.)! Registrar of Vital Statistics / ‘11--171
6 (sig ture)
....
....
.....
....
a
....: District Number Kaa,...Gs Place
......... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 57..20 13 Place of Disposition P/144 VA/1".1 04 6 14.-4/4 it/
(address)
co
CC (section) ,....--, i (loW)m ber) j (grave number)
Name of Sexton e n in C arge of Premises 0 Ce•-tf 1KO*--lAY1 CL-1
ga
(please print) /.4
Title (%/40,414/VA- i45 '
Signature / 6,
(over)
DOH-1555 (9/98)