Babcock, Preston • . \ iicz3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
NameFirst Middle Last Sex
1ies42, LCEX_i (v1ale
Dat of Death Age I If Veteran of U.S. Ar ed Forces,
— —20 t- -7 9 War or Dates otya/1-
▪ Place of Death �1 Hospital, Institutio r/ ,-
Cit , Town or Village h /e115 /f , Street Address 1�1�5 i-a l�j IIa//
Manner of Death®Natural Cause El Accident 0 Homicide 0 Suicide ElUndetermine El Pending
tLt Circumstances Investigation
W Medical Certifier ; Name Title
O 0 k Y) A
in:I Ty
Bath Certificate File � 7)1istrict Number Register Num
Ci , Town or Village s t'C�t, 0-60/ 316
(Burial Date C ete�ryy�or Cr atory
DEntombment 0?-0 3-o?03 I GV/t!id fin-ho /
Addres ./
piCremation n.,,b,,t5 Ai
Date Place Removed
Z❑Removal and/or Held
9. and/or Address
I Hold
t
0 Date Point of
Transportation Shipment
Et by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home up[.p/ MC ix /I
Address /
(9-I-Nun-il St LzLkz. Zazei-711 Ny/2xV‘e
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
III
itL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 / 3 /(3 Registrar of Vital Statistics ( C}"4 ' W
„A"-te./c4
(signature
District Number 560I Place014y /f5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 11`11t3 Place of Disposition ,9M k.Aih) Crrir�etot,.
III (address)
f}rt (section) (lot number) (grave number)
a Name of Sexton or Person i Charge of P mises ; t44.— 4411
z (blease print)
ill
Signature 1. Title CQFtMi4i
(over)
DOH-1555 (02/2004)