Rhodes, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH Ili f t r,3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
L acre, ,„ �- . f' h, s '
• Date of Death / Age If Veteran of U.S, Armed Forces,
61 J �) / .1-)- -�� War or Dates
} Place of Death /�' Hospital, Institution or
Z City , own . Village Co r. ; Street Address /` t,.3 , /t1- .. -A
9 Man • Beath El Natural Cause 0 Accident Homicide 0 Suicide ❑Undetermined 0 Pending
Circumstances Investigation
wMedical Certifier Name Title
Ci F44 ., ' L ;ebe < /V\b .,
Address, J c p� r
(s.rc_ LAi 'J.-i.r Du Sh>", Sfe'4 " �r r 1).566
Death C ficate Filed District Number s% URegister Number
City, own r Village CD ;-,t,X'(.� `t C.S 3
_. Date ,�/ Cemetery or Crematory
— Burial ' 7
/ kTy t)— Z4 ; c 6,M40'
Address f
(��
L�CremationC._ak..e.e.4...,‘...6...4c.I. I k,) _._, ra TK. 1,2 O
Date Place Removed
Z —Removal and/or Held •
"and/or Address
0 Hold
Q, Date Point of
_Transportation Shipment
E by Common Destination
Carrier
^Disinterment Date Cemetery Address
—
Reinterment Date Cemetery Address
Permit Issued to ----� Registration Number
Name of Funeral Horn �.4.smore l,.tAe-r4- l 7 ..1&. 6oit-'t-t
Address 7
Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Above
Address
CC
/
Permission is hereby granted to dispose of the human r:• • :scribed ov: -s ' •icated.
Date Issued 61/t//�..- Registrar of Vital Statistics AMO
11'17•a ire
r--
District Number Place l g :.,1 ' ' r/ n z
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Wl- giv
Date of Disposition h hSJL7_ Place of Disposition °V c y L *Ct -
2 (address)
uJ
o
ct (section) (lot umber) sivatt, (grave number)
Name of Sexton or Person in Cha-ge of Premises ,
Z, (please print)
!U Signature Title CC yaio{!,
DOH-1555 (10/89) p. 1 of 2 VS-61