Porter, Lester NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ESQ G. �'0� 2 /7'J
Date of Derath Age f Veteran of U.S. Armed Forces,
'1 CC t e .161-1�1 � War or Dates (,(j (V
Place of Death Hospital, Institution or .dlj.9�C .vc� in� Cyr
City, Town or Village Street Address Wea tip
Manner of Death Natural Cause ❑Accident []Homicide ❑Suicide 0 Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
Cify, Town or Viiiage
Date Ce etery or Crematory
❑Burial �-9 RlE /e�z,� .f �,e
Address
EqCremation
Date Place Removed
Z ❑Removal and/or Held
Hold
and/or Address
t"
Q Date Point of
0..cn ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
i
❑Reinterment Date Cemetery Address
Permit Issued to 7"S10 /0'
ration Number
Name of Funeral HomeZC /?Pjt%f_ 14v-kne-- f'^
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued�"�rf Registrar of Vital Statistics o
T signatur
District Number 7S� Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition s4- Place of Disposition / f�.�� l�kJ G,[�i"fi�/ /,07
(address)
LU
N
cc (section) (lot umber) (grave number)
Name of Sexton or Person in Charge of Premises
z (please print)
Signature Title 7-1
DOH-1555 (10/89) p. 1 of 2 VS-61