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Brophy, Jere '.4-EV,/ Cfl STATE DEPAPTMErtr OF HEACH ',Mai Recerds SrAr,rtion Burial - Transit Permit Trcr . 11 . M.o le. 0410 "4 pent Aue - il VEner an -::: LLS, meit Force 3 -7 i A .4%,ar ci Dates 0 : :1-.. Fiar.-e ,:41 Deat Izt ! , ry at r7uspital iristrutils2_, th.r) / 1-A_. itt Manner r:4 De,Fatt Naris,q! cau5c, i I Acrident !--1 H17,,,n-mirie iii sinc,d. ri Unite imed El Pending rircumsrances ---" investigaton ALI Methcal Cr lc 1: TrtiP rt M I) loki-tr-- - 1 , &I.)v -c. , , . _ _._,....._.. . Death L,ertrticale Fie Distric 4, rribe.rf i ReW,t,3- Wier-tier; i, ,,--. , _ _ ,,, _1--- i,....,Ly. n„,..qp; .:Ir v 1,7,31,-1! Li Burial mt Cate 6(,..) -rpitzery r 1 remoter,/ CI-VDDI Di:riNmAirrierit 27 Z-0 3 !Cremation ; t.- (Lei astbuij 1\-) ki ,-, mov nci.. ' I , , lz ni R.,,,,imoviii ilud;or F leld , 0-11---J . - . . t---i,, Aoldrirss l'-1 0 1 ej I. .10 Date ir;-,J,:d. T1 '1,f,'F,i 4,1rtat2i4r '::.''tt pment 40 L ',-;:-l'' - — iiv ,,,nrririon Destirintran IC -..... - .....arrier :late Cemetery Address 12,115111,9flo 1.?1 it 1 -- t- al if Cemetery Address ., 7 144,..iritQf molt ' i i Peirrri or t 15noi,x1 to Re-; striation Number _i'.4aine Or Funeral Flom? i e A4 f- 111 I „ _ . , : 5-75 - 'Ii,,Q_. a_9 Li ) ocit an La-1<k/ 1\i\/ lzSga . .. . i ,,, . F., .,„...,.,Lti V-V rn Making L',19414:A;;itiOn LA 1:^j 'y'ary, — Rernains are Shipned, if Other Mari Andve Z Address CC] Iv ,,- Permission is ereb granted to dispose of the human remains described above as indicated_ : I i Date ISSueo 2(0 ZOO Registrar al Via! SI:Jtsetcs 6 f t .._ - :. ,,,,i,r2,,,rini Nit,rorm?r o - 0,---, 00 of La,k,c`i9(050.4t. --1 certify Inat :nen romans r:,t ina ,rinc,rdafIr deiltii,e,.1 4,,,,,:y,re were. niscusec ,z,1 in accordance with this pr-erriir on. Z u,....., U.11 a!;:i....' r.:4 0L4,1', tion 21 L 144i,si ,.,.;,•,1,„.0,!,..!i.,-,q,1?..,2.`! 1 101 Name ,..-.0, Sexton cr ;Person in Charge ;t :Prem:SeS IZ 01.°17,3r,c,,pr,-1:i 11,Li Sripatureii - - '-- 1,a.,,,er: 2,01-1-,1 55,5 722,,2004,i 08/26/2013 10:45 5185483028 __ _. _ __. ..._ TOWN OF LK PLEASANT PAGE 01/01 r . , 404308 _n.NEW._friti-nlY0.1Ccc,IPA14.48TAr:rE C E PA FITMENT OF HEAL' H tViiap61:117eceozi,r1;S7aletIci 101'1 Burial - Transit Permit Ha I 1 , caivis;g:: 711*.i.elorail c U.S 1..:3:11!Forces. 1,5 2-0 I -ic coy 44Dry Villagc LCIL-Ke--. . ni a.... a) au ,,, - wormer ,. Dealt-XI Natura; . 0 IL ttPtInal GerPtio Death Certificate Filv • G 10 ref-6 V <, War c-r Dates Q. 0 Untie',- 1,,, d 0 Pandon9 Invesivatton .. Disinc 4 rnitivTd.,11 „ .. C...ir' urnStn5 . ..._ .. .__ . Yritc,1\in ;` SLIHItIrscri:::Alloci:Inrsebtsostits,,,i,1/4,:dai_tan L.A., Sex 1 Reqistier Nurnber Cjzydigp,..r v.ir.a,r6_, __ ..riscL5adt.„, i! ri 1-J Burial DE ntornhment. D4 IP 1CrPmalion rn Sevrioval ::: Li LIgik andfor - _,,, rf,g7,ss 2-49 MI5 Addrvss , ULt ii.51) j : rery r rerrijoriettro N y li;:p F-1:Etnlii''r."(1 ant.jy I-iekl , . , .. Date 1:';.11.iit.:-.11 ,r4 li. --•,,. :. 1......;! 1 rainsportettor i .., 1 ... , • rinent Cemeiery Af.fdless C.;,erne1ery Address __..„.. _., ._.., - • _ . . a,,ip_i jcp,i,,,:asrcr:::rm,,,,,::: ;:. ,„.„„. Li Flernterment Permit I ssitioKi to. Re Number i Name of F(rnegal Horn4f./Vjjer jory'tej Viirr . ;! Address bt3n7 6ict-k. //au_ 3o. 1 inito 4 LO--kii Ky tz.6,./a...... _.._ Name of Funeral Fi;m rvtiakoq Disousttion ur To Whom 11-- R.Forriains are Shir,ried. to ,Cotttar than Atiove • 2-Ackitess rc ______________ ___________________ c a' Poeormission ia ereb granted to dispose of the human renmaine descrlibed above as Indicated. ..I Dark! Issue.ce 2,(p 2,013 Registrar of Vital Slaustics •Aki 2. V., ,. .-- DISIrIC1 Number ,2055 '''''°ci; fotaoa tct.ke. 10/a5a.nt I rertify!hat;No rprroiri6 af Ulf!dee:Mont iderittiPed aftxTve were,disoosed.2.1 in r3ccordance with this per atiC on: Ott Cla;e. of Ofsposition 9-.)?-/...i Place or Disousilion PI•Je \ii‘Ai Q4.14241A lzrz y S' ..,..trk...m.. -- LA4 AZ . ... . _. . o ;loin rirawc-rii...moneo o in Name al Sento r ..r5 n arce at Pre,rnmes . Z i,1:047.4:17.0,ar,no ' lti i .._ (over) :DOH-1 5,56 102120041