Collins Jr, John t ^ .il ca
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section w Burial - Transit Permit
Nam First- Middle Last Sex
\John R C0l1 ► ,-s Z-r. MaI
Date e/_o_ f Death Age If Veteran of U.S. Armed Forces,
111 lO - 1 ( AD) 7 ?9 War or Dates I C/ao - K e
. 14 Place of Death Hospital, Institution or
To City wn r Village 1 nc i oz.- Street Address 3'�Y1 KNi.,5 Qk 28
Manner of DeathEi Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
114 'I Circumstances �Investigation
ut Medical Certifier Name Title
44.
Address
Gien5 +aid KCY
] Death Certificate File District Number Register Number
City, Town or Village 1 nd tin axe, aos 3 (om'
0Burial Date //^^�/_ eten �r Crematory
<'''El Entombment iJ u -1 "l - 17 • 1 1 nee Y 1 e. t ) ✓7Y'm I 0 rU
•
Address .
`.ti4Cremation L( f,-)jba.tLi M1 •
Date -Place Remo9ed
❑Removal and/or Held
and/or
Address�;;;
Hold
tO
la Date Point of
Transportation Shipment
t by Common Destination
iiiiii Carrier
< Q Disinterment Date Cemetery Address
Q.Reinterment Date Cemetery Address
in Permit Issued to Registration Number
.;:i: Name.of Funeral Home M 11 ler 7,1 /YID / HOM 0109 l 9 .
Address/ 357 /VyU R-PG 28 / nd(Ct.ti Loi''-- /V IZS'1L
i Name of Funeral Firm Making Disposition.or to Whom .
14 Remains are Shipped, If Other than Above
Address
tt
ILI
'`` Permission is hereby granted to dispose of the human r m ins described above as indicated.
Si IiiDate Issued �- 0-I 7 Registrar of Vital Statistics lib.
(signature)
District Number Place i
Lai I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
P 1 l i I i7 p 1 tt� �r i+r.,.lii Date of Disposition (v Place of Disposition
,cv
(address)
Ili
W.
Cr (section) (lot number) (grave number)
0 et
Name of Sexton or Person in Charge f Premises As .Sbv/ll
(pl se print)
Signature b Title Oran
(over)
DOH-1555 (02/2004)