Hayes, Wayne F Ohio Department of Health
Vital Statistics Removal from State Permit
Permit no. 1692652
Name of Deceased Date of Death
WAYNE F HAYES December 23, 2020
Personal data sex Age Place of death(Village or City) County
on deceased Male 74 Years DAYTON MONTGOMERY
Cause of Death
Manner and 0 Burial 111 Other(Specify) Removal from State
place of Name of Cemetery
disposal Pineview Cemetery
A satisfactory Certificate of Death or Provisional Certificate of Death has been filed as required by the laws of this state.Permission to dispose of the body
as indicated above is hereby given to:
Authorization Funeral Director Address
to dispose of ZIMMERMAN, BENJAMIN A 53 Quaker Rd.
body QUEENSBURY NY 12804
Registrar/Sub-Registrar Re istretion district no. Date of Issuance
YANNUCCI, MICHAEL 5501 December 24, 2020
HEA 0
Rev.01/07 This permit must be retained by superintendent or person in charge of cemetery for a period of five(5)years
I
Public Health Law Sec. 4145(2b)
012832
Receipt
Human remains of , � ,. ti , -=- 1 4J - delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# €
HAYES
NAME
Wayne F. Hayes Age: 74 la
\......„--/
Lot Owner: Leslie & Marie Hayes
Lot# Oneida 109 Grave# 3
Case: Concrete
Died: 12/23/2020 Interred, 2/30/2020
Funeral Home:
Zimmerman (county) Montgomery
Cemetery: Pine View Cemetery