Morehouse, Karl NEW YORK STATE DEPARTMENT OF HEALTH 015
Vital Records Section Burial - Transit Permit
Name First IG1:c,(i `- Middle Last Sex
Date of Death Age If Veteran of U.S. Ar ed Forces,
/1 a/r I 2_ 73 War or Dates W 6
Place of Death Hospital, Institution or
tuZ City, Town or Village-7-'ou *, t4 c j Street Address 5:1S^ (p��„a jot0,4-c._
a Manner of Death IT Natural Ca se O Ac ident O Homicide O Suicide O U determined O Pending
tit0.
Circumstances Investigation
tu Medical Certifier Name Title
'(c- 0 1/( (.).eras ik P
Address p
..t-f'04 6. 4c. C rs- 7/ (i,
Death Certificate Filed � District Number Rester Number
City, Town or Village`s ( •foU cp s"7 is-/
OBurial Date Ce etery or Crematory
O Entombment �3 - ad/2- PcA P I)//P w .c.4r
Addd ress
[Cremation -Li QuW1C�,'� p�ORp�s/� � (1 12. t1
Date Place Rerh'oved '
C ORemoval and/or Held
and/or Address
I= Hold
CA
0 Date Point of
O Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /la �r `f a, c) p_ll-Pi! D//3 U
Address / t L f a. C4 1 y ' { 11 1 v
Name of Funeral Firm Making Disposition or tom
Joi Remains are Shipped, If Other than Above
Address
it
Ili
97 Permission is hereby granted to dispose of the human remai fis described above as in'ated.
Date Issued U — . ..torl. Registrar of Vital Statistics .iob
(signature)
111111111 District Number 0 S'1 Place_0� 1C za
::::. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition iI//lilt Place of Disposition ,.lU,ty (.c dthwy—
(address)
111
CO
re (section) (lot numb (grave number)
CY
ca Name of Sexton or Person in Char a of Premises r=�}C 3anlif"
«z /� r (please print)
Signature (ice \ Title diem pat,
1, (over)
DOH-1555 (02/2004)