Brothers Jr., Harold NEW YORK STATE EPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First ''JJ Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
6�/// J b W�oor Dates KOAITA,J
f—�P c,�e� of Death / (Hospital)Institution�-o�;r
"C' ityiiTown or Village �L�,.�s / �ZC,S Address l 7 Ge i_ I (9ZG._..S
p Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
fl
Address
Death Certificate Filed District Number Register Number
City, Town or Village S Oi 2 7 2
Burial Date emeterr remato{y
67 /di/
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❑Entombment Address❑Cremation -Li ti-vim I Y
e Ue2 '4 Q wcA., _A / Z s-d y
Date Place Removed / i
aZ❑Removal and/or Held
F and/or Address
N Hold
O Date Point of
NQ Transportation Shipment
5 by Common Destination
Carrier ,
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 't G,/ncij j 0, maker lcr 3_1 i-kv;'> - _ O f i t-I
Address I 1 Q1-G.-y Q fl ;'. , &k..LCC.nSbu(y , N P v._.1 Ju V_ 12 si U,--�
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above _
• Address
Cr
d" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued b / i s I/( Registrar of Vital Statistics _ �jCv.4.-,._q, W_��
(signatur
District Number 360 J Place 6 lszA^S t')k \\S, N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 6/15/2011Place of Disposition Pine View Cemetery
2 (address)
WLO New Kenesaw 23 B 2
(section) (lot number) (grave number)
O Name of Sexton or Perso in Charge of Premises Michael Genier
(please print)
W Signature )2' ^� _ Title Superintendent
(over)
DOH-1555 (02/2004)