Shippee, Harold • NEW YORK STATE DEPARTMENT OF HEALTH
V W 3LSr
Vital Records Section #Y ., Burial - Transit Permit
Name First M1 le st S
NoCm1 ,, �.� abe.....,
Date of Death AR!. If Veteran of U.S. Arm orces
7 / 7 a ,, / 41 War or Dates n G V —7 k
of Death - Hospital, Institution or rr own or Village r0.G 5_ z--_ Street Address VA. PI e�;c4 L. C�L`,t
;, , anner of Death Na l Cause El Accident El Homicide Li Suicide f Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name /A Title
.s` Kw4lr Z A � (�1 ,b PVA YI e1L, r
Address
goc) 1r� n A-v,1,,_e.) r`c�u N ;v_. . ' i-s ii 0
Certificate Filed District Limber / Register Number
Cit y, wn or Village r;1`„ s.� 3300
LJl urial Date Cemetery or Cremato
DEntombment ���7 /a�,� i`ft ev,Ac...� >r +^Cr, 1-1,-
' Address /l
(.Cremation t,�e 2.4% .-w lJ 1 0� v
Date f Place Refnovedi
❑Removal and/or Held
and/or Address
14 Hold
ta
0' Date Point of
i 0 Transportation Shipment
ti. by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
sa: Permit Issued to i Registration Number
Name of Funeral Home c�.nSn^ r� Eger a. I± ,t'k"0 -)--,____ 00 4+471
Address7 Site rA.,A r`.- 4
Name of Funeral Firm Making Disposition or to Whom/
Remains are Shipped, If Other than Above
:�= Address
441
Permission is hereby granted to dispose of the human mains descri d above as i sated.
Date Issued 15 mole Registrar of Vital Statistics t N `�
( L (signature)
District Number,3 00 Place COUNTY OF ONONDAGA
E_<` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 1 13-11 Place of Disposition 'f/r. Li Ca►ri ttrim -
(address)
10
CC (section) /A/ (tot number) �, (grave number)
® 1 h
Name of Sexton or Perso in Charge of Premises riskr> r' S41414-
(please print)
Signature 4-1....., -- Title `ruv�`
e6iiii
(over)
DOH-1555 (02/2004)