Hill, Geoffrey NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section E uriaO _ Transit Fermat
- l' Name Firs Middle Last Sex
(1COM{..1 (YV
, :. Date of Death pp I Age I If Veteran of U.S.Armed Forces,
`'``' 1 z 12-01 0 1 `3 ( War or Dates
11= Place • a Bath I Hospital,institution or ( '^� /
City, tow or Village ( �1III Sb�.I'� eel Addres �S 1 . /,/tiuf11-Gt(h.
Manner of DeathiwNatural Cause D Accident f Homicide Suicide Undetermined ri Pending
Circumstances investigation
uj Medical Certifier Name Title
'Maw 01Lff Curb Ku(
5 2 .�u41tihddov?.Crk n.s Failc j ago
:- Death a tficate Filed ) Di t' ber Register Number
City own •r VillageC),IjC,ef14/1A40t,t,ty 1 -,` una1 Date Li ) Z � o rem t ry
IAS❑Entombment ���5
Address 1„ _
OCremation
S2 Zee vt UUZP S�ci � N 1 i 2
Date I Place Removed
X — Removal ` and/or, Held
— and/or Address
Hold
0 ' Date Point of
coTransportation Shipment
5 by Common Destination
Carrier
i- El Disinterment Date Cemetery Address
A Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home &.l`1C= ,�L,Z 1 �-10-c \ C-2,1 l 0
Address _
1 t L_,..,c � ~` ` -- :-- L 1 , l\ IZ Cat,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
re
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued) '� /r C ) Registrar of Vital Statistics �C^c, 08,
-- � (signature)
District Number ,c(y1 Place f o 1 n
>. I certify that the remain of decedent identified above were i pried of in cc r ce with this permit on:
5
lid 2t /7 s1L.
Date of Disposition � Place of Disposition fi SSW
C- U (a ress)
l
it (section) /44 �t number) (grave number)
zName of Sexton o Person in Charge of Premises �"
Z (please print)
Signature Title
(over)
DOH-1555 (02/2004)