Green, Kenneth A NEW VOHN STATE DEPARTMENT OF HEALTH
Vital RerordsSection -- Burial - Transit Permit
Name First M' tlk Last Sex
Date of Death G^^ c Age If Veteran of U.S. Armea Forces,
Vese pates
Death //� HmgTBI, Ire4tuXon �c u r
c or Villa may ..-Is Street Address
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Circumsuvn Imws '
yl Medmal CerlXier Name v1 Tilt
Address
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D M1 Gertilicat Filetl DUMW lu Register Number
It for Mil J. ejLt5of
Barialw Date (7 $ , JJLL Cemetry or 61 .Jo
OEnlanoment Address
rttCremation
❑Removal -� s. Held Puce Past
andtor
and/or Atltlres
HoM
Date Panto
[]Translwrtation Shi ent
bycommon Deldral
Carrier
Disinterment Data Cemeery Address
❑ RDMOment Dale Cemetery Address
Perms lssuedto L ftgudalion lJamber
Name WFunerel Ham G^swn Lnnenl roe ��.( DeYY6
dtlress
vc G,..+k OJT (age
Name of Funeral Firm R Other
Men Above
a to N1wrn
F Remains are SM etl, XOMar Men Above
;a address
4 Permit"" is hereby grantee W aiapow of Me Nam.n real described alas Indicated.
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., Signature YI Y- This �ItRI^d'IW-
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DOH.1555 (f1y2C04)
Public Heal law$ec. 4145(2b) 012769
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