Brown Sr, James f e - A
NEW YORK STATE DEPARTMENT OF HEALTH Burial a Transit Permit
Vital Records Section
Name First S Middle _Last Sex ✓1I
be slit.. rbrowr.. Sr
':: Date of Death Zn Age . If Veteran of U.S. Armed Forces1 Yj [il War or Dates
P ace of Death l,. /�,� ç
�'� .6' a1: In titution or S r SQ m61�'� SC
'} Town or Village(.50' /
i i - ner of Death Natural Cause fl Accident Homicide fl Suicide ❑Undetermined El Pending
la Circumstances Investigation
la Medical Certifier Name oiLmTitle
Address r qk1s ^^ A' 2v�9O
�� �a� �C S'C• t�l�S N Register Number
:« Death Certificate Filed (-n S r I� S District N 560 ' cj 7
'tom own or Village ('�
re :unal ! Date 3 ) .30
1 Cemetery or remato
❑Entombment Addees
Cremation Y a. ��,,Q,Prv�S bl�v i N y 1 2 e��
'`` Date lace Removed
Removal and/or Held
and/or Address
tZ Hold
0
I Date Point of
41 Li Transportation Shipment
t by Common I Destination
Carrier
•
I Date Cemetery Address
Q Disinterment
n Reinterment
Date I Cemetery Address
<' Permit Issued to � Registration Number
Name of Funeral Home 4.. A'lE.' �t t1C_<--GI NO cc C•i 1 ?C
Address \1 LcSa>t . `4- L Ce2A- -:; i / Il \ 1 C Lk
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
f
EtiPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/36 /1 Registrar of Vital Statistics r j. Vv
(signature)
c District Number S &O / Place C, `s F L 1 / Al
14)
'`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
!Li Date of Disposition 313)I 0 Place of Disposition ont icy `,
(address)
1.41
fil
(section) (lot number) r (grave number)
iz Name of Sexton or Person in Charge of remises 4 Af`: 0,4 ytt
(pise print)
ila
W • Title 1'3i
Signature `'
(over)
DOH-1555 (02/2004)