Norton, Donald t 3?S-
NEW YORK STATE DEPARTMENT OF HEALTsc1 . , p
Vital Records Section Burial - Transit Permit
Name First n Middle Last Sex
SJv FYic'l l�6cLyt_4-- f Vc 2 is (•-.) /yo-z
Date of Death/ Age If Veteran of U.S.Armed For es,
60. 12.( / ?-_ 3 - War or Dates ,v16
14 Plac- . --th
- lion or
X T Ci , Town o Village )Lr' rrePetttaAl-c4idres �7- 9/0 ?v L-a,j
. Man - . •eath❑Natural Cause RAccidetit D Homicide ❑Suicide Undetermined ri Pending
Circumstances Investigation
LEE Medical Certifier Name Title
g.4. rouc. rEig-c_07.7/9A) /`-i b
Address iil:i! 77 097---) c7- . e-Jdytivugws a clvt- A/V/2-P P _
Death - to Filed D ict Number ( Register umber
C ,Tow o Village ) 6'0
[]Burial Date / Cemetery r Crematory
❑Entomtxnent 6 22. / Z / t.%.7,)&' I)/6--..)
Address
>, Cremation U the Q (S 2 Z,-O y
Date Place Removed
❑Removal and/or Held
and/or Address
iti Hold
Date _,_ Point of
ei 0 Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reintetment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home uy no d €ater F,inej-cd +to rr _ 0 i 1 3
» Address
11 La- y(2_fie_ S. , Queensbu.ry , New Vor1.,_ 1240y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,2 Address
at
Permission is hereby granted to dispose of the human
ins described abo as indicated.
Date Issued 6 -as -I Registrar of Vital Statistics 7.
(signature)
District Number 5 (o So Place 1`)-;v1
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
ttj Date of Disposition 4 I7S'I Ii Place of Disposition FNokV Crw,/f oiiv"
(address)
4
IX (section) (lot numbetj J (grave number)
a Name of Sexton or Pe on in Charf- of Premises n, t441'
I I (please print)
,: ::: Signature Title C11. i pt
(over)
DOH-1555 (02/2004)