Albano, Albena NEW YORK STATE DEPARTMENT OF HEALTri - s `7
Vital Records Section Burial - Transit Permit
,t- Name First 4 Middle t Sex
Iz
`: : Date of Death/`' / Age off Veteran of U.S. Armed For ,
/d PI //3 93— War or D.11. AY 0
Place u *-.th Hos• r,(, Institution'. (�
•
City ' Village Gj 0 A-LE 6 UeLy Street • .. l if { J N S o 1/4)
Man ' DeatITWatural Cause El Ac9ii6ent IDHomicide El Suicide Q UndeterminedLjr-i Pending
Circumstances Investigation
Medical Certifier Name 0 Title
CI JU 2i9AJni6r L z- L3 Iii.)
Vp-
Vp Address 1f2_
.SThhoe,- _(ing....) ,-4hi---, Q obre-A4sE 0-2_,icate Filed District Number ister b er
r Village Uci�`sC U jC { /
Date f / Cemetery Cremato `�
El Burial /o/ 9 // 3/
r.J 9- M6-1-3
Address P-10
::::p4 .Cremation Qk v,g iL� UrAu.f-Q Al
Date Place Removed
Z❑Removal and/or Held
M /'
and/or Address
a Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
:: Q Disinterment Date Cemetery Address
::::: ❑Reinterment Date Cemetery Address
.� Permit Issued to Registration Number
;
r Name of Funeral Home Haynard v, 3Ct-ker Funeral Name, p/130
Address
a lI La a.y_e#e cY. , bc,uznsburc� ,lUe w Vor) 1 'Oy
f Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ains d 'bed above as indicated.
q. Date Issued/CA -j I1,3 Registrar of Vital StatisticsC_ CL A_(�.. (si ature)
'l' District Number/ Q S Place 1 �1- C �j L)•-•p���L---"
I certify that the remains of the decedent identified above were disposed of in ac ordi36e with this permit on:
Date of Disposition/0/0-/3 Place of Disposition 6Q,,,,,c V c / � 4-
(address)
iLi
iA
fl
(Section) „ `%�i�7ml/) (grave number)
Name of Sexton ers i ge of Premises
4l i'Signature el
(please print) ,..., -744.
Title
(over)
DOH-1555 (9/98)