Daniels, Oliver ...
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last -Sex
Date of Death ; Av ; If Veteran of US, Armed Forces,
. ,
War or Dates
. Place of Death
City, Town or Village
Manner of Death i....jr—i
I I Hospital, Institution or
I Street Address
Natural Cause 0 Accident L.Homicide E Suicide 0 Undetermined ri Pending
ul Circumstances '''"-'4 Investigation
ta Medical Certifier Name Title
Address
\
10_, -a.th Certificate Filed fi_ k 1 District Number Register Number
;.'Ci9, Town or Village 0\CA\c'D c0.\\
' aurial 1 Date
12.-\k--\-2\ i Cemetery or Crematory
`\: i\c\s,- `(-)•-,-3 Q, C(\()°\ _
DE ntombment
Address
Date ; Place Removed
Removal ; and/or Held
1---j arid/or Address .„
Hold
_ .
Date Point of
0 Transportation ;
; Shipment
z by Common Destination
Carrier
„....... __.
. - Date Cemetery Address
ri Disinterment
..e-------
. Date Cemetery Address
- El Reinterment
Permit Issued to 1 Registration Number
Name of Funeral Home IA% .\'.. ' -\-\ I 5)\&11)
Address
'..Y.oP V\CKe CN . ".al\ "%\i'N (6\fl-X\-C''' CC-SL\N A \Iv:5s
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped; If Other than Above
2 Address
tr
ta -
A. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (21 V-11.262.1 Registrar of Vital Statistics 0Ct. b.e--( 1/1C0t}ed-
e..fsigeettur )
District Number (:)\ Place 0 ter 1.\--5-4-SJ
,..
,,.... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition alle(li Place of Disposition eF,Z.jie... ZS--
Z. .
(address)
ta
4n.
2§ fsecttara; II Limber) (rave number)
ta. Name of Sexton or Person i Charge of P ises f‘ri44L,
.
z ,please t)
La Signature Title
(over)
DOH-1555 (0212004)
r r
Q .1.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#