Jones Sr, John NEW YORK STATE DEPARTMENT OF HEALTH e - .-`1 ILI
Vital Records Section Burial - Transit Permit
Name Firs_ Jddle Last Sex
\/1 A h f• ul-I e 5 Sr. Ai L
Date o Death i Age Veteran of U.S. Armed Forces,
,5- o3 D e g 7 r If War or Dates 5
Place Bath l Hospital, Institution orye
'Z Cit Town o Village 0/1-eg n j Street Address /)o? c$'c 'L gm„ j-6
Mann eath4-Natural Cause C Accident C Homicide C Suicide n Undetermined C Pending
Circumstances Investigation
fj Medical Certifi r , Name _"/� Title
G , ,/e0,-) /' ,09. IL/!n /`b-)
Address
6T c At-/774e0 5r &)/ / .
I e.- // /i/Far €yz /a8t7
Death Certificate Filed District Number Register Number , ,
Cit(wDr Village 4//p �p� `, 7✓`� 2 -2 CIEf,.- , ,
Date' C tgry or Cremator ‘
C Burial I c/%1/9 /� �l e)e /VIP(usekJ /Aa/v --(22L'n-7
Address
Cremation I -le tk) 6 � Pn S deice
Datei Place Removed
Z —Removal 1 and/or Held
O —and/or I Address
Hold
L______I Date Point of
55 C Transportation Shipment
0 by Common Destination
Carrier
Li Disinterment Date Cemetery Address
r. Reinterment
Date Cemetery Address
Permit Issued to Re istration Number
.
Name of Funeral Home \/ZGSQ4 4e, him fe _i!?G �e93/
Address
. i3O;66449/45 SZee-.6. - ZU1'/‘- '7-"/-/4-/7 W. TA" ile?cf- 7
Nam- of Funeral Firm Making Disposition or tc Whom
Remains are Shipped. If Other than Above
o. Address
' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ', .e, '7� ;ac..1, Registrar of Vital StatisticsQ,f �,/4 t . rt •,�' ,
/� (signature)
District Number,5 7.. Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ),fiec/`` ' Place of Disposition t;,)a'v ( (.,,=n --r,'"j.,t Cs--
2 (address)
14.1
0
CC (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises C (^ L_, ;r.h -f,{ -
Z d (please print)
W Signature 'L r ;r.,c Title L rti ri•.-fiL (
DOH-1555 (10/89) p. 1 of 2 VS-61