Cook, Bruce NEW YORK STATE DEPARTMENT OF HEALTH Zf
Vital Records Section Burial - Transit Permit
Name first � Middle n��� - �
Last S k
Date of eath AgeD If ,Veteran of U.S. Armed Forces,
-�� oZ3' (3 t War or Dates' t"
#,;. Place of Death ; Hospital, I nstitutio or
City Town or Village QA Street Address tst-t o)
anner of Death ]Natural Cause El Accident El Homicide El Suicide 0l hdetermi ed Pending
_ Circumstances Investigation
a Medical Certifier Name Title� e
Addr s
53 Myr 11- _ ar-a ei
Death Certificate Filed � trict N mbe� Register Nu ber
City, Town or Village
Date Certery o. rematory
�1
❑Burial _'l � � �' �� ;�„ '� �'1 R �c �,c,�l �k,M -U
Address f
Cremation � �L (1(L '
Date J Pla e Removed
a❑Removal and/or Held
and/or _
Address
N Hold
2 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Re 1st ation,Number
Name of Funeral Home �,� C� 1 L� r ZL rill�, f k) L Ewalt
Address �"`l
DA- eituti\ si Lcoo,_ t_ili-ti-k_Q w ric.4
Name of Funeral Firm Making Disposition or to Whom
r. Remains are Shipped. If Other than Above
Address
Permission is h reby granted to dispose of the human rem ' scr. ed aVy,ve indica d.
Date Issued Zli.� Registrar of Vital Statistics
SARATOGA SlS
District Number -I D 1 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition �=3 Place of Disposition -Cvu (.rfserioc-:uv.:
W (address)
N
X (section) An pk..o t ynumber) c (grave number)
GName of Sexton or Person in Charge of remisest;,�lt
z (please print) 1 '
LU Signature _ Title C11-601liT L,
DOH-1555 (10/89) p. 1 of 2 VS 61