Sherman, Clyde NEW YORK STATE DEPARTMENT OF HEALTH #59.9
Vital Records Section t I. Burial - Transit Permit
Name First , L s Last Sex
Date of Death 3Middle.75-
Age _ If Veteran of U.S. Armed Forces,
i 1 /t / o 1 Z ‘,5 War or Dates
t Place • 1-ath Hospital, Institution or
Z' Ci - .Town •r Village Street Address 3 C.- /A .Z 0
WM-. -r • Beath 0 Natural Cause 0 Accident 0 Homicide D Suicide E Undetermined 7 Pending
Circumstances Investigation
W Medical Certifier Nam Title �A T
4 FA. L �, 1 t:0-�. Ai.
Address-� / �/J J�
t-- :�-r Tz c<<. C'a ., 6 Leak N.Jt5- 0. Y 18O1
Dea 'ficate Filed District Number Register Number
Cit -own r Village Calk; - Ltss3 gOL
_. Date J Cemetery or Crematory
Burial t 1 ! 13 ( ac,i2_ ; tie V;�,.,, ofc.�,..ti 41:5r
Address v
..Y.Cremation ( �-�c?-c^S(,,,,t1 ,fie..-' / a.4 P toi
Date U 9 Place Removed
Z — Removal •
and/or Held
—"and/or Address
0 Hold
0 — Date Point of
NTransportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home e--LS.Ko"c Act4 L I J,,,r,c 1„. O0 Ystfr
Address (
( ate/n„r,-. 7-11 E f�.r. r 3 �
; Name of Funeral Firm Making Disposition or to Wt6om '
Remains are Shipped, If Other than Above
Address
i
Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued I /,13/ 61L_ Registrar of Vital Statistics
'___ • a re)
District Number 1 5_3 Place "�wA r�
) - ,`,c� � Y , fa cisak
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I--
w Date of Disposition (( 1131ft Place of Disposition Phu U40 (/Nn-dat►t
2 (address)
W
N
¢ (section) / _(lot-number) (grave number)
0 Name of Sexton or Person in Charge Premises f'a Jen,*
Z 47` (please print)
W Signature Title cooinwroyt
DOH-1555 (10/89) P. 1 of 2 VS-61