Ott, James NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Male
»` Date of Death Age If Veteran of U.S. Armed Forces,
1 13 97 War or Dates ,
Place of Death Hospital, Institution or
tip, Tows ofikqtft Street Address 6227 late. 9N'
Manner of Death�Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
?V
Death Certificate Filed District Number Register Number
qtyf TownffV#4qp Ha y.e 4��8
Date Cemetery or Crematory
El Burial 12/1 / ? ;,nE? v1 Pr,= Crerna.tcrV
Address
®Cremation
Ci�eens^t ry, NY
Date Place Removed
Z Removal and/or Held
P and/or Address
Eh
Hold
Q . Date Point of
y[�Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brew eer Funeral Fow r ,tic. 002211
»> Address
24 C�urcr St.. , T_,a.ke r,uzerne, NY 12816
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 ?2/16/g7 Registrar of Vital Statistics �j
(signature)
District Number t j f Y Placer��L`' Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Date of Disposition 7 Place of Disposition 5z'/V. //,�V C/g /��70�F/
(address)
(section_) t (lot nu �'/?AAJ
(grave number)
Name of Sexton Tr Person n Charge of P emises .��4� D '
(please print)
Signature Title G S -77
DOH-1555 (10/89) p. 1 of 2 VS-61