Noonan, Mumford james NEW YORK STATE DEPARTMENT OF-HEALTH 9 � 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
AG
Date of Death Age If Veteran of U.S. Armed Forces,
�`O15 War or Dates —
}- Place of Death Hospital, Institution or
City, Town or Village Street Address a a 1.5
Manner of Death RNatural Caus ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
C �
Address
5LU �-ed�.-raj
Death Certificate Filed District Number egister Number
City, Town or Village 02 4
'< ❑Burial Date 1� I Cemetery or Crematory
�l �v j
❑Entombment Address
Cremation ;
Date lace Remov
❑Removal ��7and/or Held
and/or Address
h= Hold
Date Point of
En Transportation
Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Q, 063624
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tu
Permission is hereby granted to dispose of the human remains described above as ind' ated.
Date Issued Registrar of Vital Statistics
(signature)
District Number O 2- Place
I certify that the remains of the decedent identified above re disposed o ccordance with this permit on:
l.yo cf
Date of Disposition IITII1a Place of Disposition 'I/ne ►i ZI ��
(address)
(se ion) (lot number�t/-/ ( ) (grave number)
Name of Sexton or Person i Charge of P emises �-✓6 f k16 7)d ���&7-�'
(please print)
Signature Title
(over)
DOH-1555 (02/2004)
i
Public Health Law Sec. 4145(2b) 013 Pf 4 6
Receipt
Human remains of '^ delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#