Canale, William NEW YORK STATE DEPARTMENT OF HEALTH z • V li ' .% J tit
Vital Records Section Burial - Transit • ermit
Name First Middle, Last Sex
L)'I1/iGr1„ V(nce - for m
Date of Death Age If Veteran of U.S. Armed Forces,
q l ( l �`� 3 War or Dates -KOfe Cc.,
Place of if
Hospital, Institution or
3tt City own or Village��S c+._f 1S/ p Street Address Lo � �r `1=i (Y -) A'_—
a Manner of DeathNatural Cause ❑Accident ❑Homicide El Suicide ri❑ Undetermined ❑Pending
/`��' Circumstances Investigation
W Medical Certifier Name. Title
CI r I c haul �I k i t c MD
t^^ Address
Death Certificate Filed 1 n_ District umber Regist Number
it Town or Village e-nSc�.p L
�� 9 i I � SIn . � � �9
❑Burial Date �/ /
i
C ery orCrematory cx9j1.013,,A:❑Entombment 1 ' Z���
Address I i_
;,cremation Q Lt c I�.t— 6 n 1 C› . -i'
Date Place Remodt
2❑Removal and/or Held
and/or Address
H Hold
O Date Point of
a., ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home e9 ,1a 3 / �.. .,, .� —Ii 3
Address a
. C 9.0 Y l / I
Name of Funeral Firm Making Disposition or to Whom C, U W
Remains are Shipped, If Other than Above
Address
CC
Ia
11` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9`j Li/L3 Registrar of Vital Statistics (Jo CAmysai0
(signature
District Number 4 6/ Place .4',"s /" '//f }" /9 J /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z '
11.1 Date of Disposition '1ji�It3 Place of Disposition .�►,NgUjti., C,ur+—
(address)
W
Cl,
CC (section) (lot number) (grave number)
0
a Name of Sexton or Person in Charge of Premises o
zr I�� rplease print)
Signature 41-- Title OLVII iAL
(over)
DOH-1555 (02/2004)