Brown Jr, Maynard g . i
NEW YORK STATE DEPARTMENT OF HEALTH Sir
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
mwil WA IA rd ro w �1- , to
i<: Date of Death Age I If Veteran of U.S.Armed Forces, j�
-112 1. I War or Dates i �3 — v,,JiCA&)� Ll efbrf
Place of Death Hospital, Institution or / I
illCity, }' or VillagekA_LeAs6. / Street Address 9 CoUVV17\-1 chub ed. _
.0 Manner of Death❑Natural Cause D Accident 0 Homicide RI Suicide Undetermined Pending
Circumstances Investigation
jj Medical Certifier Name Title
mice` ,j ,e';1✓tIC MT
Address 50 . ,road St. Wart -hfol N lai gg.
Death Certificate File District'Num yR inter Number
>< City, ow�r or Village4k0 ukc b(A/N ...7 , i�t��� (c
❑Burial ' Date .1 J
Iwo_ [[ Cemetery rem
❑Entombment Address 1 Kt v I
,,Cremation Qv� 6 - , (iujL t b �1� / 1" `t (2g6LI
'"' Date Place Removed
Removal and/or Held
9. I--
and/or Address
trt
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
'=;Q Reinterment Date I Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home &..V'at ire_'- \ 1\p cc\t C 1 t -'0
Address
1 S.
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
CC
1Li
tt
Permission is hereby granted to dispose of the human r ma" s des 'bed Ms
indicated.
Date Issued l�1 I —) Registrar of Vital Statistics C�
(signature)
District Numbers Place 1 < }
.E. :;. I certify that the remains of the decedent identified above were disposed of in accor with this permit on:
fit Date of Disposition 1-1-(j Place of Disposition ,u V.,../ arm Ofnrx..,
(address)
ua
to
ge (section) 99t number) (grave number)
Name of Sexton or Person in Charge of Premises af.rste� � ��
z �1 (pleas print)
t! Signature Gil Title lir►'Jfjpit
(over)
DOH-1555 (02/2004)