Cathens, Lincoln NEW YORK STATE DEPARTMENT OF HEALTH _ i Z
Vital Records Section Burial - Transit Permit
Name Firstfiddle t Se
/ I C4L,� "I.p U cam--1�,ti S /i8-Li
5iigg Date of Age If Van of U.S.Armed Forces,
tt ( , l / Al "2 J War or Dates — U,JJ io . 3
R. Place • a-ath or
Z. City,Town •r Village O ,J;SQ Street Addr ? CU6'1,.-G456/6- (. k(
la
Manner of Dea Natural Causeent Homicide Suicide Undetermined Pending
1 Circumstances Investigation
Medical Certifier Name gg r Title
Ecttr ?e, ri 2
Address
..
µsI 0SQ; I00fii1- ai 11i pi.'
....
Dea I. - _ ate FiledQ
Distndt Number Register umber
C' . Village 0 g S 2
_i❑Burial Date / Cemetery Crematory
0-3
'<❑Entombment 3 / (.J 4/ U/
Address f
Cremation C� i 'L� ...� -� U7, ,/V
Date Place Removed
E Removal and/or Held
�... and/or Address
Hold
Date Point of
ti0 Transportation Shipment
by Common Destination
= Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
A Permit Issued to Registration Number
Name of Funeral Home 1-ia nard 'D. akef- Funeect I H oar Ott 10
s==> Address 1 1 Lcc-ra e-�H e Si-r ee t j``� '/
.r- y , �Clt2e t,.1.-
nS� �lj i �C'_trl� 7C?r- lc 1la8 b
vq
=` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem i s described above dicated.
gifi Date Issued el-- 3-ddi, Registrar of Vital Statistics /'V.
(signature) —`—
District Number S79 S 7 Place Olou_ji-Diii.z.... �
0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IN Date of Disposition to(Li I t3 Place of Disposition .g.tjL Cr, Or it","
(address)
11
al
(section) (loth`�'�) ,u1 (grave number)
ti Name of Sexton or Pers n in Charge of Premises f.s L £ NU t
.Zr (pf se Font)
10
Si nature L Title -
(over)
DOH-1555 (02/2004)