Reamer, William NEW YORK STATE DEPARTMENT OF HEALTH N
Vital Records Section Burial - Transit Permit
in Name First Middle Last Sex
1_1 [ «� ltr'/ts K9a -2f iliavit
gi; Date of Death Age If Veteran of U.S.Ar Forces,
Ill 3 -°/ 7 /` Pa War or Dates - Ycia.,
44 Plac- 'each Hospital, Institution or
Ci , To n •r Village sr--) Street Address/0 ,.tap 'I�1��� aee
pekei,
Ma •- • beath ONatural Cause 0 A•S•ent 0 Homicide Q Suicide ❑-ndet ined Pendingt Circumstances Investigation
Medical Certifier Name • T e
Address
.. 3f l l nn `/ l
``r�� Deat toFile �•�' �D' ict 1Vu b������ ' e iste��ber
o illa e 1-
-v:; City,Town / g C - 'i
Date Cemetery or C,ratory
❑Burial 0 5 �� � i2�'. (/� /1/ )7e. c� G✓
Addres
Cremation ��t P_ 6 c• A.,i 0
Date Place Removed
t❑Removal " and/or Held
and/or Address
E Hold .
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
<>: Permit Issued to Registration Number
< <; Name of Funeral Home
} A• ddress
aie e,A76,___ _&I /2.5V r
iv k:
"=°_� N• ame of Funeral Firm AA�king Disposition or�Whom
Remains are Shipped, If Other than Above •
Address
Permission is hereby granted to dispose of the human remains described abov �s indicated.
75
3 Date Issued ) icl Ic: -C))a Registrar of Vital Statistics 6 -- C. �r�-,
(sign re)
`i D• istrict Numbe �9.'S Place d is .
L-•.
I certify that the remains of the decedent identified at3ove were disposed of in accordance witrythis permit on:
0.
Date of Disposition 3-.)0 --I Place of Disposition i ,ne u('e.L) C^e wr4o r tA.7 VYt
. (address)
X sec' n) , (lot number) (grave number)
AName of Sexton or Person in Char of Premises ( irnn4H.r t Xuy'lIt°
Z !�- (please print) �
W Signatu?e tL, , 4 eL_ Title Cre 'tc� 5 1 •
(over)
DOH-1555 (9/98)