McDonald, John NEW YORK STATE DEPARTMENT OF HEALTH ` < i �0 S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RE -TV HA) ' Do,JAW HAtt�
Isii Date of Death Age If Veteran of U.S. Armed Forces,
liiii flit-/ /g, . 0! 6 . ; War or Dates
ii4 Place of Death Hospital, Institution or
iii Eity, own r-Vi+lee ^f tj ,9 E.,441 Street Address in/// w ii / rE/-
Manner of Death® Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ n etermined ❑Pending
U Circumstances Investigation
Medical Certifier Name Title
Ci AILS / = /-_L).
Address
111111, / {, . 0 e Aiic_i —4/2..(7 /2,D . z/'/ /'G,q GJo, /k.J/ /2.4,Yr�
Iii Death Certificate Filed District Number Register Number
i , Town or Vfft ge 1W O fig* ELAA /,.. -6D
Date Cemetery or Crematory
❑Burial .,7/3-' / ga P/AJL. U/I& cr,- -:"A j ai-y
Address
E Cremation
Date Place Removed
Z 0❑Removal and/or Held
r= and/Holdor Address
Q Date Point of
pi ❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /fZ (' 4i je �4, coy‘
Address
3/0 A'/Z.4Ir.I/,tC. /tt' eAk.rr AAc/`J ill /2(y�
Name of Funeral Firm Making Disposition or to Whom
titt" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human emains described above as ind�'cated.
f.- ` P
pii? Date issued 0 7//J 2 Ot. Registrar of Vital Statistics 'L b(t, ' , (A-AAJ U.t
l'�
(signature)
ligi District Number /,.•go Place L,Ak_E-/L,e4e4 p IV mot. Ezzo4. 4(
I certify that the remains of the decedent identified above were disposed of in accordance with'this permit on:
f-
ifi Date of Disposition 1 t3--t%w Place of Disposition Pi , , (f , t4
2 (address)
JjJ
0
CC (section) c, i (lot number) (grave number)
GName of Sexton or Person in Charge of Premises ,t•i, .,1r,,,
(please print)
W Signature '-°'A, Title L'rrrn. kijiv
(over)
DOH-1555 (9/98)