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Wilson, James A
NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Biostatistics -Vital Records Section Name Fir*—, Middlen Last Sex Ila Date of Death Age If Veteran of U.S.Armed Forces, 9 D 5 War or Dates Z Place of Death Hospital, Institution or Hain r /Ih City,T i..a I : Y. �. Street Address 0: Cause of Death �` :U.............:........::. .............::::::::::::::. :::: :::::::::: .. .., ...:::.............................:::::.:::::::::::::::::: ::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ........ Medical Certifier Name / Title n !l �........................................................................................................................................ Address . f e-R i ............................... .................................... . . . . Death Certificate Filed District Num er Register Number City, m nr /illacw yl�Z4 Date p Ce tery or Oratory El Burial D l(J . . .. .... . ....: .. .............. ®`Cremation Address �.:..:... _... ....... ... :..: _. _. ............................................. Zi Date Place Removed ❑ Removal and/or Held and/or Hold ::::................................... ......::::::::::,::,:::::::::::::::::::::::...........................:................ ::......:::::::::.:::::::::::::............::......:::.:::: : Address i� Date Point of N' []Transportation by ' Shipment Common Carrier ................................................................................................................................................................................................... C] ..:::::::.::: .. :........Shipment ........ Destination ...:.:::.:..::::.:...........:.............::......................................:..:.:...................................... . . ................ .:.:..:::.:...:.:...:.:.:................................................................::::::....:................... ❑ Disinterment Date Cemetery Address ................................................:::.....: ,::.:....:.. ....................................................................................... El Reinterment Date : Cemetery Address Permit Issued to , 9 Re istration Number Name of Funeral Firm __ _ _ _© a7 Address .....:.. .............................................................................. .................. Name of Funeral Firm Making Dlspositl or to Whom / ,. Remains are Shipped, If Other than Above Address 7 Permission is hereby granted to dispose of the dead htimany`remains describe above as indicated. K� Date Issued Registrar of Vital Statistici�? %�, `a .z '`, ignature) District Number ��� Place X1 — I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Place of Disposition /'/r/�.E� L'/ w; Z. (address) W',. ' (section) (lot number) (grave number) pName of Secton o Person in Charge of Premisesr'`�/P� Z (please print) .� , lu Signature Title � .E/1'!/�LOIP�� /�S�I DOH-1555(9/86)p 1 of 2(formerly VS-61)