Juckett, Burtrice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial o Transit Permit
; Name Firstel Middle Last 1 Sex
u
MAIi 02. dq SCt(tett I f
<= Date of Death Age If Veteran of U.S. Armed Forces,
I ' 100 War or Dates
Place of Dea ' A ���pN I Ho - io o
Z City, Town o(Villa e iS A i I S treet Addre (;(r r' c . Aft, - /®
la Manner of Death fy i Natural Cause Accident �Homicide 0Suicide Undetermined n Pending
Lt4 �1 Circumstances investigation
Lu Medical Certifier Name n Title
Address
f o.a c km-- 7 -/ CL e'er S /-A SI Ait'/
Death Certificate Filed i District Nu ery ster Number
=? City, Town o(Gillag'el lQktxIJIS `�{ 1 7, -
<>❑Burial j Date S i I I i Cemetery o remaD'el
M ;
tiKi
❑Entombment 1
Address �,,) �/•
&Cremation � � -C • OMNI-4�. (y ' / `�' " VOr 1�
Date I dace Removed
. CRemoval , and/or Held
and/or Address
Hold
cil
Date Point of
Transportation I Shipment
by Common Destination
Carrier
❑Disinterment Date 1 Cemetery Address
Q Reinterment 1 Date f Cemetery Address
Permit Issued to ''� + Registration Number
Name of Funeral Home 1 ;\'\a \,.\e cx\ hoc t CT t 1 L
Address �-- :
>_= Name of Funeral Firm Making Disposition or to Whom
II Remains are Shipped, If Other than Above
Address
i"
LGi
S Permission is hereby granted to dispose of the human remains described above as indicated.
-:: Date Issued 2� Registrar of Vital Statistics Cc
/ f ` (signature)
District Number .�� Y Place ////j /Q t 6 f 1 S
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
1t Date of Disposition . /9//7 Place of Disposition di VAA'Ve.A,i Gfakeor-÷
(address)
kta
Sri
ix (section) 1 (19t number) (grave number)
Name of Sexton or P s harge of Premises J t^ �fG vt ��'j'la.c�Q
2 /J( (please print)
LE Signature . ��% Title G-i2.-.'l.ra/�
(over)
DOH-1555 (02/2004)