Boles, George il t13.5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section £ . Burial. - Transit Permit
Name Fir / ! Mid le Las Se /
,De -4s-
Date of De /� Ag If Veteran of U.S. Armed Forces,, I �
TA/ 7 p� , 2 War or Dates w
'Crof Death /� Hospital, Institution
, Town or Village(L�L � 4c s Street Address 7e'//..5--
anner of Death(Natural Cause El Accident 0 Homicide 0 Suicide El Undetermined 0 Pending
�
Circumstances Investigation
tii Medical Certifier Nagle Titleg:),. ,..D4/2/—61 L- l-c?rf:0--)1
ly E.
7 t a r�Address U l 62-e&ikir Z 4f�l Y /�e2/
D th Certificate Filed ( �� District Number// Register Num er
Ci , Town or Village ( 7 ./✓ (-(p./ v;V
Burial Dat � �j ry,Ccemato(ry� fpJ0/Teiiier---
Entombment ��� //7_e t/ /0f,/,/h,
,g Address l
Cremation Uii r 1 eG Ri cfa�`er ✓ " 1 /7 .
Date Place Removed
gEl Removal and/or Held
and/or Address
f= Hold
0
Date Point of
cL
fj)❑Transportation Shipment
Gs by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
s Permit Issued to / �i/ , _/� Registration Number
, Name of Funeral Honk /Cj?i 14. G / 710ii f- 6 -60//�7
Address ,"' - S-/— 74 t-2/7 /t / 1-P//
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LEi
Permission is her y gr nted to dispose of the human remains descr' ed a ov s in d.
Date Issued U Registrar of Vital Statistics
�� (signet re)
District Number . . Place et � �� - c ./1,4 2 r�
mi
,..,.: I certify that the remains of the decedent ide tified above were disposed of in accordance with this permit on:
la Date of Disposition q Ii 113 Place of Disposition ,P,,4ty edevriti'4'o -_
1 (address)
Cl)
cr (section) tot number) C (grave number)
fa Name of Sexton or Pers n in Charge of remises t ;1 t9r Sl'w
2 ii (pte se print)
1 Signature L L)-� Title CL t i ToQ
(over)
DOH-1555 (02/2004)