Holman, Richard NEW YORK STATE DEPARTMENT OF HEALTH 'S?cS
Vital Records Section Burial - Transit Permit
Name First r Mid4 Last Sex
12iC1-/,i L_ . /4)4,mA-1k! (v)iIL
El Date of Death Age If Veteran of U.S. Armed Forces,
�,41` I i :aoC War or Dates
Place of Death / t I Hospital, Institution or r
ii City pawn aw or Village I or I /1 5 EA(R y Street Address 5 Gi t4 c�E. Ay
c, Manner of Death®Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined ri Pending
Circumstances Investigation
ra Medical Certifier Name Title
G1 FtI i/i44 PK-ANT- a 111-
Address
/0J Pou.crty s!R-1-' ' CvI/ ,72MA«, Al /28'7
':> Death Certificate Filed District Number Register Number
,�itq, Tjwrror Village I o j EA1 R/ /5 2 Q.-
Date , or Crematory
❑Burial i 7/400 6„ p;fiezt.,16-1,2 c/2e-rhq-TO2y
A'Pr
s/
Cremation FE1Is E34_�r• ,A/ /27os!
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
= Hold
0
0 Date Point of
136 Q Transportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to .� Registration Number
Name of Funeral Home /j./c110) , I/o ) pi ,, m o/as y
Address / _ter
11 y ,,z ,_,y
Name of Funeral Firm Making Disposition or to When
[ Remains are Shipped, If Other than Above
04 Address
la
Permission is hereby granted to dispose of the human remains described ab as indicated.
Date Issued 7�/7/ao(o Registrar of Vital Statistics /` LO )e3c r)
1 �}(�si�gn�aturee))/�� /� ,((
District Number 15aa Place Poi Ii i. , / /� L/02 f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f ^�
wDate of Disposition 'a!i t L, Place of Disposition z'k 10 x<,.., Cc`t° .qt�P'` J IN,
2 (address)
Ui
N
eC (section) f ((lot number) (grave number)
h Name of Sexton or Person in Charge of Premises ( -, k^.)Ate-
0
Z ')f (please print)
W Signature U.h/t�-� i•*.�.�' Title (v�ym ., v(
(over)
DOH-1555 (9/98)