Cromie, Brian NEW YORK STATE DEPARTMENT OF HEALTH - jc
Vital Records Section . Burial - Transit Permit
II Name First Middle CC" Last Sex
D r i (AA A-41,;-c IA
Date of Death Age If Veteran of U.S. Armed Forces,
7 3 J'3 9")� War or Dates
11 Place ofDeath� (/ a o Hospital, Institution or
Ci , T wn o Village�,q,Kc. L z er n-e._ Street Address R.v� A �acl'...�1( -r I1r
Man eath❑Natural Cause rg Accident El Homicide El Suicide ri❑Undetermined Pending
i Circumstances Investigation
tot edical Certifier Na9�jj�i Title
Al PTic.LaeL SK ;P: cq Mt
Address t , 1
�D �et,� ��•, waft-Pry, t 1�, ( g
:::::
Death - ificate File ,/ District Number Register Numb
City,MP.r Village q,lki� 1‘.ic-t•1 t_ 5-6, S 6
Date Ce etery or Cremato
iii ❑Burial 7/ 5 /.2at r t\e ;t_w fetia4Dt
Address ei
®Cremation ( ..-t-etks 1,......t i, Y•
gDate � Place Removed
0❑Removal and/or Held
. and/orbiTi Address
Hold
0 Date Point of
y❑Transportation Shipment
ES by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �� Registration Number
^^
Name of Funeral Homer e A cLIAS \ T.,.,4.1•4 L "... . D e 4-73
ei Address
N. Mo... yl-: AA..s se_no.� N ,►. )3 2_
::::' Name of Funeral Firm Making Disposition oi'to Whom
Liz Remains are Shipped, If Other than Above
Al Address n
I
iiiit Permission is hereby granted to dispose of the human ..m ins des ibed abov as1 idicated.
-IL.-
1�L
'< Date Issued 7-y3� Registrar of Vital Statistics [.
(signature)
District Number 6`7,� Place //115' , 10Z-e£/%
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F ' I
5 Date of Disposition -it 13 Place of Disposition _?s,,Uu%J CIZ.dtif rr•_
2 (address)
LU
CA
CC (section) t num er) C rave number)
GName of Sexton or Perso in Charge Premises J
g ,, (please print)
44 Signature Title
' .' (over)
DOH-1555 (9/98)