Belden, Edward - # -)sol
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs MR dAmiyldle8 .o ) Se, 4f�tA lY( l
ate of Death_ J" �� / Age 7o If Veteran of U.S. Armed Forces,
ate
T r / War or Dates
t- Place Bath _.,--, Hospital, Institution or Zip �1 /
City, ow�or Village GD/]���Q d(-� / Street AddressA ,/A,j mynOAJ S #5.•T�ti111h
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ending
tai Circumstances Investigation
Medical Certifier Name Title
s7/�,�,/ (h, Qm n�' f1'Ib _
Add{ 0 ! //CCIQ/ , /V A, Y /03 80
: d
Death Certificate File District Number Register u ber
<> City, ow or Village //Ca11hRQ6 A /5-4 T
< OBurial Date prnetero ,Prernato
y Entombment oi �� " ` G l R E 1'1'1 A`T-O g y
ai Address 21 /(Cremation ( LIFN� .S/3 U ley ALk.) 1/412k_
Date Place Removed
D❑Removal and/or Held
.- and/or Address
H Hold
iy}
tj Date Point of
0.11 Q Transportation Shipment
in by Common Destination
i<3 Carrier
0 Disinterment Date Cemetery Address
>l Q Reinterment Date Cemetery Address
gii Permit Issued to J Registration Number
Name of Funeral Home W;I /\ C 7 A/J O/,e02
Address
///4/94Ak„N) SI. Tro/e/ Oc A, IVY / ? 88.
Name of Funeral Firm Making Disposition or to Whom
tO Remains are Shipped, If Other than Above
Address
i
l
11,7 Permission is hereby granted to dispose of the human re ains described
yabove as indicated.
Date Issued fah 9//3 Registrar of Vital Statistics Ldii 1, /)
(signature)
District Number/,5 it Place // 4,eO 6 A 1 /f y
�.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition is 1431(3 Place of Disposition ZA, erc ar i--
E (address)
tti
ix (section) (lot number (grave number)
Name of Sexton or Person in C-arge of Pr ises t1 .number),_
5 ease print)
Signature Title mrt+ -
(over)
DOH-1555 (02/2004)