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Jordan, Reginald .7 r NEW YORK STATE DEPARTMENT OF HEALTH • # Vital Records Section Burial - Transit Permit Name r First Middle Last Sex 'e Q / i i I C dal 4eA.) a Date of DeaX Age If Veteran of U.S. Armed Forces, / jz-- / , v© & (O War or Dates .1 Place of Death Hospital, Institution or Low r:d A City, Town or iliac 6 r) (/i/le Street Address /9- (� / Qj/lli?Cu ,�/K, Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending I Circumstances Investigation Ili Medical Certifier Name , Title ',la k" Pr05s07a ) Address 9 Vo 1 ,5f 6 `' r n ui.ll.L' 177 cii /2 y 3.Z7 Death Certificate iled District Number Re,g�ster Number City, Town or illa 6722)t iv le, 7 2 5 / 7 ❑Burial ate �}emete fatory El Entombment 2 , 00 t9 I'l /ti{' �i eW or Crematory i'{�ILICL �l 1 GP 7/1 Addr s &Cremation j e 51,u,' -t ,-7 J Date ./ ace Removed 9C ❑Removal and/or Held and/or Address F" Hold IA 0 Date Point of ct Transportation Shipment C by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to A / Registration Number Name of Funeral Home e�,b.�r1 4/1`t�� knior ``� Art_ 0I ?-3 Add es A f /,,,, V.�G l 1-. ( IaI'llo l-e , 7)y / 2 SS Z Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ,2 Address IU Permission is hereby granted to dispose of the human remains escribe above s indicated. Date Issued (OfZ/o 6 Registrar of Vital Statistics ignature) District Number 5 7-Z,5 Place /0(del ��� I certifythat the remains of the decedent identif d abode were disposed of in accordance with this permit on: P i Date of Disposition 6--S Place of Disposition ` vc C) �-1--O-t J�/ _`T' (addressILI ` CO 11 (section) (lot num er) (grave number) aName of Sexton or Person in Charge of Premises R\..( G i4 14, Z (please pn 14 Signature a:av' "l Title ciEr- 4-{'", re_ (over) DOH-1555 (02/2004) ti