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Auclaire, Jerry NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Est-' Middle Last - Se zit/ Date of D- . Age If Veteran of U.S. Armed Forces, ��/ - /ei /,..3 7 / War or Dates 1- Place_of, e.,,r ----•� Hospital, Institution �� JJ W City�w . Village ql�/!7/'1,/`c-f- Street Address yo")-7 �(C k //-/ re., Manner of Death atural Cause A c�t 0 Homicide 0 Suicide �Undetermined Pending Ul Circumstances Investigation W Medical Certifier, Name 7 Ti e Address A2 ie,__Jc:i , --/-7., 42Q ,,, .i ./6 z z-/ ail'zz , Death rtificate Filed_— / District umber Register N ber City Town r Village (9�//I f ,6 Ur , ICa 5 J . o- OBurial Date l Ceretery-orCremator ❑Enmbment //3/�©! ,/Lj (/L� ! ��t/�U//!1.ii Address,V,el ec k� 6t/e&izr-Z �(7 - V / r Ei cremation (��// �/ Date Place Removed ❑ ? Removal and/or Held r= C Hd/ldor Address ano t? Date Point of 1:15 0 Transportation Shipment Q by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name Of Funeral Homee(p .4)-7 !72 4F //kA - G - ©//j Address Ii4 S_/ Ni: / Name of Funeral Firm MakingDisposition� � G�� 1�j or to Whom Remains are Shipped, If Other than Above 2 Address ix t: ilL ` Permission is hereby granted to dispose of the human re described ab ve as in icated. Date Issued q- )3-)3_ Registrar of Vital Statistics signature) District Number 5 (p . 3 Place OLL.,i," e.9-2 % ad n b/ I certify that the remains of the decedent identified above were disposed of in acthis prdance with it permit on: 2 lii Date of Disposition 11u.f13 Place of Disposition Zeikd C ta� 2 (address) 111 CC (section) /_ lot number) ( (grave number) Name of Sexton or Person in Charge f Premises Ai Sw. ';� � (please print) W 4L Signature Title C90.400t (over) DOH-1555 (02/2004)