McQuain, Lloyd NEW YORK STATE: D PA .TMIENT OF HEALTH 44 5
Vital Records Sector, t )1 Burial - Transit Permit
Name s fiddle ..0 0 S?'� S,ex1
LLD y.� o'11U- Lsl O67 /%8L&
Date of -i Age If Veteran of U.S. Armed Forces,
/ //2- / Z. � War or Dates Aj 16
ai } H stitution or
411111) o.r : r a �tQr,js /U S Street Address 9 / i 1251 ,
p ►annei ui Dep.tnVNat,atul Cause Accident ( 'Homicide L Suicide Undetermined El Pending
a Circumstances Investigation
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nth C i r-,t > a .- District Number Register ber
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of
1 S,,r,.,, - Cemetery &Crematory
�, . / 43 /l Z 1 1til c�" t.)/61-J
(_,rerT arer . U497`(.----- -- _..... _ 06Vo a
Place Removed tiV77- 71--
17 -7L and/or Held
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p-", H,)i,;
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10' Point of
ai'cii Irani ._' Shipment
Cemetery Address
Date Cemetery Address
F ';*. Registration Number
• i y i- - L' 'ttel 30
Address
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� v,-.s 70 L 12 si 0
N..-TF ;;- ' (. -. �r, ^. ek;ag Disposition or to Whom
,-- R mains are -poci. ii Omer than Above
Address
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lePermissior is hereoy arantea to dispose of the human remains described abov as i is ted.
I A‘rj '
ir_,.. :; D/1,3/26/2— Registrar of Vital Statistics
(signature)
'.rift v ;t 4,0/ Place j ypo `/ ii>i
+!,. - a-rife ,t the lecedent identified above were disposed of in accordance with this permit on:
D , L ;,.a inr/12 Place of Disposition 40i.w Crwei ONl.
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(address)
,... (:5ert,oni (lot number}- (grave number)
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Name nE :` xr Soar e of Premises LI e"111
(please punt)
i r ,, Title Ca etY)KOIL,
(over)
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