Bunzey, JamesNEW YORK STATE DEPARTMENT OF HEALTH . �,6%
Vital Records Section Burial - Transit Permit
Name First Middle Last
L
Sex
DeathAr
FAqi L/
If Veteran of U.S.Da6 d Forces,
War or Dates TA 2 - I 6j 1. -7
Place of Death
ri, LAY
Hospital, Institution or
—ICA
City, Town or I a-g r-V 14:��
Street Address L.11
PS,
Manner of Deail"'�atural Cause 7 Accident Homicide [] Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier /% Name Title
�I)VZAJ4 Co L-S Q �J Nu�-� 07*cr niotov*?-
Aqdj
Vh ess
V
- -
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Death CCertificaMtilecd
District Number Register Number
517 0
. I I I I ag City, To
City, Town or ilia
❑ Burial
ry C"er� or ato
X
I❑l
[]E ombment
rematio..
Alens
C�)opvpa-- R>� �2&Ll
M
Date
Place Removed
❑ Removal
and/or Held
and/or
Address
Hold
Date
Point of
IM,
❑ Transportation
Shipment
by Common
Destination
Carrier
❑ Disinterment
Date
Cemetery Address
❑ Reinten'nent
Date
Cemetery Address
Permit Issued to
�DMIE:
Registration Number
Name of Funeral Home Lm'e-
Add
MA A) S Lkio
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission Is hereby granted to dispose of the human remains described above as indicated,
Date Issued I cf Registrar of Vital Statistics
(signature)
District Number 6Z-b Place DL�-Lo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition -n Iii Place of Disposition
141
(address)
(section) number) (grave number)
Name of Sexton or Person in Charge of Premises
(pleas & print)
AFq,
:7 X:
Signature Title 't
(over)
DOH-1 555 (02/2004)
Public Health Law Sec. 4145(2b)
012552
Receipt
Human remains of
Pine View Cemetery
Official
delivered one �� , 20 I
Y �t /
Represen g the eral home named on burial permit
Funeral lectors Reg. or License #