Hemsworth, Leydon J. NEW YORK STATE DEPARTMEM OF HEALTH Burial ' TrenSIS Permit�
Vital Records SxTw
Name Fnt Middle tied Sex
xafaoe J. w tb
Date N I Age If Veteran of US. Amretl Farces,
07 / day 2020 'I'I Wm m Dated
H. Place of Death Hendon. ItuM1WOm or
CI , Town or Yl NIItee Street Address fa Parallel ifter
Manner of Death p NaOnel Cause ❑Account p Homicide p Sudeten LiUna mire EPendng
Circumstances Investigation
Medical Call Name Title
gmad A. calcined' Im
Address
59 throttle at Y300, 0¢st'ga amities., Am 12e66
Death Demands Fled Rs0ids Number FagMtm Imlwr
Cry, Team or Vi cities
]Bunal Dam 07 13 / 2020 mewym Ual Firm vine Ctaant'ay
I]Enanbnent Md s
❑cremation Ouemab ", as
pPare"m Date Plait Randall
and/or Address a^Nor HNd
Hold
O Ows Potr N
❑Transportation ment
by common Dnrnelim
Carrier
p Disinterment Dale Central Address
p Raintermaid Dore 9ery Atldlena
Permit Issued to Registrelio0.. .......6 et
Name on Funxal Home c'.vafaio'ata hues ral Cars
Address
less N.vl. Ave., e.raovs an., m 2e66
Name of Funeral Firm Mekirq QSlsmibsn or to NTvn
Ramains ere Shn , XONer Or Above
Address
6
PermissionL
me
d W fifteen W me human remains described el Illdlpbd.
Date IssueReg®trar of Ville sM"m #//z if
%ems—
' Denied NuPlat miltoa , Intel York
I candy tlw dewtlart teral�sumee same dlspaed ai InawardencawYNplb ltran:
w DateNOt PlxeMougniYon (/A0.r
I and
emi(Name of Stlmge of f� 6 nitmVSignaWreTitle ItMNAL
lavarf
DOHAMS 102/20041
Public Hea1N Law Sec. 4145(2b) <) 126 0 r
Aeceip
Humor remains of f—� o^ IIeMS aeu.ere on _. 20�0
Nne Yew CememY NePe+eauo Ne(uvaellwme n>maluo1Qt^n��
Mfieial FwvW Dirswrs ReB.mliceoupJJlas(—