Burns, Barry NEW YORK STATE DEPARTMENT OF HEALTH 3 5
Vital Records Section , t , Burial - Transit Permit
iiiiii Name First 11 Middle Last Sex
Q 2y atoArt J3u2145 11Ak�
'`� Date of Death / Age If Veteran of U.S. Armed Forces,
€ s M AGt (9.3 Woe 39._ War or Dates /U6
"lake of Deatfi City, (�� Hospital, Institution or
Town or Village JNRAT Sf R fni9S Street Address, gi24-ro 4 Se,7A- 1
: anner of Death Natural Ca e Accident 0 Homicide Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Certificate Filed District Number TJ 61/ Register Number
<; City, own or Village`�14( To�A- �2IAvCS J �.t,
Dat 9emet or Crematory
❑Burial HAY a1-1, WO( 1 i ivc. v iew f. netv)11-7-0r2 4
Address /�
:::: El Cremation Q ufl-t<1 .2 RD O U Ke N Sb oic AI V
Date 1 Place Removed /
. g . ri Removal and/or Held
and/or Address
gHold
Date Point of
u Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Aii Permit Issued to Registration Number
'=`l Name of Funeral Home
Nr< Address f L� �
al -1", 0 U62.;--"K IS Orly Ay
-: Name of Funeral Fi Making Disposition or to Whom
Remains are Shipped, If Other than Abov
e
Address
Permission is hereby granted to dispose of the human re gl:e4p, . as:in ' ted.
ii Date Issued dk Registrar of Vital Statistics
.:; (sig ture)
iiii-ci District Numbers Plac
a —
I certify that the remains of the decedent identified above were disposed in accordance with this permit on:
f
WDate of Disposition ' %x Ni /''t, Place of Disposition -+fi I(.." •-,- .1 v+ '„
2 (address)
ILI
Cl)
it (section) ,-l (lot c number) (grave number)
° Name of Sexton or Person in Charge of Premises >� '
Z -? 1' (please print)
Signature C „s\, .-.„ - Title , ti� ` ,
(over)
DOH-1555 (9/98)