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NEW YORK STATE DEPARYMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First .�- Middle Last Sex
Date of Death Age If Veteran of U.S.Tv,.
Forces,
a I/ 3 / 0 i3 . -�_.. War or Dates
Place of Death Hospital, Institution or
TaityDTown or Village ..-}D i S r Street Address Ls.)e`-le }I. C_G.
anner of Death L3Natural CatGsk Elcid�nt Homicide Suicide Und rmined Pending
W. ���V///// Circumstances Investigation
iii Medical Certifier Name Title
Addres
Sc--1,,.--4-04- .
Death Certificate Filed SARATOGA SPRINGS District'Number (/v Register Number
ity,,3own or Village
❑Burial Date Cemetery r Crematory
•❑Entombment '1 1 5 / a of Z ;, c v;�..._i C-i °ct�r
Address
siCremation �cer.s (� � 1�.,� jr/L
Date 3 ) Place Removed
g❑Removal • and/or Held
and/or
Address
Hold
O Date Point of
fel• El Transportation Shipment
6 by Common Destination •
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address .
Permit Issued to Registration Number
Name of Funeral Home .r�s n' r� - H. 11,.. 0.'t't`g
Address �
7 •
S k r .,., Ave_ / �r: rU, i i s .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
to .
` Permission is hereby granted to dispose of the human remains de ' dLoveoveabindi ated.
giiiii Date Issued j 7i Registrar of Vital Statistics
(signature)
District Number ��/ Place SARATOGA SPRINGS
;.' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tii Date of Disposition `1IS1h , Place of Disposition "-torts, afrct-OfN.-
(address)
/LE
tfl
1r (section) r (lot number) (grave number)
ci Name of Sexton or Per n in Charge of Premises t )( SPAY
lease print)
Signature Title CcM1¢i02
(over)
DOH-1555 (02/2004) ,