Shattuck, Herbert H. NEW YORK STATE DEPARTMENT OF HEALTH a f I ipi
Vital Records Section { - Burial - Transit Permit
Name First 1 Middle Last i Sex
Date of Death Age If Veteran of U.S. Armed Forces,
>> j /a 5/a g War or Dates
14 Place of Death Hospital, Institution or
City, Town o uIlage � L,.� Street Address LJ. e-c tir-,-c.
ILIc Manner of Death[j Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
0 Circumstances Investigation
tu Medical Certifier Name - Title �M
Q �CU c_�r
r - A 1 K.... Y"`
mi
Address lel (^1 4v
Death Certificate Filed District Number Register Number
gii City, Town or Village r:,, _
0Burial Date Cemetery or Crematory
ii: 1 C/ -7 /20 ;siNe.---ti L.: 6:CA^g477.------
❑Entombment Address
[NCremation CX�GCA> bar `� Ny
Date tiJ ' Place Removed
Removal and/or Held
4:2❑and/or
Address i;;
U
Hold
C? Date Point of
ta Li Transportation Shipment
0 by Common Destination
Carrier
iiiii
m Q Disinterment Date Cemetery Address
li Q Reinterment
Date Cemetery Address
gi Permit Issued to r Registration Number
: Name of Funeral Home 6-4. s,,D rc - -J ).-,.___ a . �`t"
iiiR Address
SA?r� /—Ve 70 ( /-a'6 a-2_—
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
Permission is hereby granted to dispose of the human r ains des ribed ove indicated.
Mi Date Issued lc /a'S�c Registrar of Vital Statistics'
signature)
liii
District Number `+-SS-3 Place c. r,,,—t-t, i ) `''
I certify that the remains of the decedent identified above were disposed of in accord ce with is permit on:
2
ill Date of Disposition /0_ /ZljiO,Place of Disposition
,address) J
Ili
ix (section) t number) (grave number)
Ct
ta G '
Name of Sexton or P o in ChargA of P ises L � k4k
ii lnleate mint)Title 6/ it . •
Signature _
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) a 1415 4
Receipt
Human remains of delivered on - , 20
Pine View Cemetery Representing he funeral home named on burial permit
Official Funeral Directors Reg.or License#