Seary, Harry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section r . ,• Burial - Transit Permit
-; Name First / Middle ('�' Last S
t��J� C.>9� J �Ltf
y7
«r Date of Death A ff Veteran of U.S. Forces,
` /�3v/)Z 3 or I SSZ) /Ss-'2
__$ P e of Death }-- Hos Institution oir- J S c
' ,own or Village066,).i. !`/ L_S ress �`ou,
g 'annex of DeathINa Ural Cause []Accident ErHomicide-❑Suicide ❑Undetermined 0 Pending
Circumstances Investigation
-''; Medical Certifier Name / Title
J tifTo P l L. / 4-1.)
Address
._.. / 0 Z-- ealU L. c(7- .i atr-,1/4J-K Fei-6j
>? •-:••, Certificate Fled District_Num•-. -krnit oarply Reis r
City r,, or Village Lt°,-t-3 Fa2•L S II
'-❑Burial Date I Cemetery
-= QErrt Add p u
ress
ilk le, emation a Lpex L,t � 6) U C &". /3 o/`--7
, Af/ ,
Date Place Removed /
Removal and/or Held
for Address
Hold
Date Point of
t Q Transportation Shipment
�; by Common Destination
• Carrier
El Disinterment Date Cemetery Address
-• .;[]Renterment Date Cemetery Address
pi': Permit Issued to Registration Number
- <j Name of Funeral Home 14G no,/a-i Pxtker Fuller cat n-•r� C)]13 C
• Address It Lai ye.-ie- SA- , Qu_eensbury , Ne York_ i2saL
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
• Permission is hereby granted to dispose of the human remains desert e afbove in ;:
It'== Date Issued ® /0/01-v/1- Registrar of Vital Statistics i �
( )
District Number ,540/ Place C/, ,*, 1
>. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Q r1 Place of Disposition (2.t� GN.,4art+ti.
FcbZiz0t2, { )
3ill
(section) 4 (lot number)( (grave number)
2 Name of Sexton or P on in Ch of Premises C (•3+�r e h-4 ik
Pia)
S nature // 6 Title (te m R T d
(over)
DOH-1555 (02/2004)