Shattuck, Patrick I(NEW YORK STATE DEPARTMENT OF HEALTH' it 307
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
T�i9j7ic,e G- 54W7AC,Z /1iiN I
Date of D ath Age If Veteran of U.S. Armed Forces,
�L�/� 79 War or Dates
1- Place o Death 7/-/,4S,,c.4QI. Hospital, Institution or
ILICity, Town or Village Street Address 40/iepV.Mer- /-C9 /I/4
Manner of Death Natural Cause ❑Accident W. ❑Homicide ❑Suicide ❑Undetermined ❑Pending
t Circumstances Investigation
W Medical Certifier Name Title -
Address
/vo/.7771 G,Qt = ,<6f}L?fir Ct./, 2-
Death Certificate Filed District Number Register Number
City, Town or Village OV,ikttfAft//'�r S Z3
0 Burial Date Cemetery or Crematory
❑Entombment A � ////t/Eki
Address
Cremation QG// ,‘/J,P/ Y
Date Place Removed
E El❑Removal and/or Held
and/or Address
t= Hold
U)
Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /F_Azi-717 7/2z 0042/ �;, L /7747 DOvey8
Address
7 S, ximiA1 4ht- Wg/4/72, it/Y / -2-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
0
l
LI
Permission is hereby granted to dispose of the human re al s de ribed abov as indicate
Date Issued /3 Registrar of Vital Statistics ��)( �� 1
.r;,, 1�
(signa ure
District Numbers J Place `J�
.I cI certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
k ,1
ILI Date of Disposition (4ly lit Place of Disposition -�i,..vuv 644,11 orwfr:-
a (address)
UI
0
#c (section) /n . (lot number) (grave number)
ci Name of Sexton or Perso in Charge of Premises G A(i bA r DevAli-
5 please print)
Signature /j L Title CbtelOak,
io
(over)
DOH-1555 (02/2004)