Miller, Peter NEW YORK STATE DEPARTMENT OF HEALTH if 't * Li j
Vital Records Section Burial - Transit Permit
in Name i Middle Last Sex r- . j //e)--- /97
Date of Death Age If Veteran of U.S. Armed Forc ,
il 08 - g- - d-f7/a� � es
3 _ War or Dates
Plac- • Beath Hospital, Institution or Z Ci i , To -'or Village iubuceri5 Street Address /J 7 C�h '$c
Ili
i Manner of Death ': Natural Cause —_Accident 0 Homicide —Suicide Undetermined '—Pending
kti —Circumstances —Investigation
Medical Certifier Name Ti
itti
o £ rnouc rs �A h A ntl�e�
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Address 76� L A •
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- RticicC niy . 0-9476
mi Death ificate Filed /' r District Number Register Number
City Town Village 68'111/ dl� l j.s?
Date Ce ry or Cremaatttory
❑Burial - a-b - P0/e1, W20/eio (! r‘a4. rs7/4
Address /7 ) /
: ::�Crcmation lam' (JQca, �),s b4,t�� NAY'
Date Place Removed
" Removal and/or Held
—and/or Address
}= Hold
0 •
.Q Date Point of
a. Q Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
iiiiiiiiif Permit Issued to Al'! I Registration Number
<s Name of Funeral Home EJJei �, /K / ,IJM'A/IV t-- Oa-_</7
Ini Address 1
e.,.d
ig!
:i>. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
4 Address
•
<tLI •
Permission is hereb granted to dispose of the human remains described ve indicated.
Date Issued d5' a Registrar of Vital Statistics i
(signature)C
V District Number /7 c1 Place Aille.Lci C>,,,0 Afj .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition B-n4YL Place of Disposition Pt()Lb,/ :Cr„„iorio►•
(address)
ill
CC g (section) �y(� number) .�r � (grve number)
9 Name of Sexton or Person in Char p of Premises L /�►, Jeh
2 (please print)
Signaturedi7L Title C/1it.Ih1ij-oQ
(over)
DOH-1555 (9/98)