Foley, John NEW YORK STATE DEPARTMENT OF HEALTH '` # il 1
Vital Records Section Burial - Transit Permit
Name First Middle t I Sex J IT)
J- S -- _h I
Date of Death I Age i '; If Veteran of U.S. Armed Forces,
I t Y 1 (� j l War or Dates
1-- • - e of Death Hospital, Institution or
City, own or Village / a, _ / I A Street Address - : Ay 6 6
n anner of Death Natural Cause C Accident ❑Homicide D Suicide Undetermined Pending
W Circumstances Investigation
Medical Certifier Namt ("s Title
Address
i3 0 s--tai0ou4e, q Lcat, or oo'l raW
Death Certificate Filed 7, i District Number egister Number
di City, - own or Village ,) �s ralh 1 D601 I ��`�
■ :uriai Date 1 Cemetery or Cremator
If (9 I I g -_ fr l/ feLo Crerncd-Dcj
❑Entombment Address
.1i remation c Lu _ Crd t,❑ Qu>�nAbe _`1 , p
Date • Place Removed
f Removal and/or Held
Nand/or Address
Hold
• Date j Point of
0 Transportation ! Shipment
3 by Common Destination
Carrier
E Disinterment
Date ( Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homei CI
( �� � t,r1 c cal 1�t� , `- 4 l -
Address / _
h Lac-ckyc H SA-. , C,z,_k_c_c.n bL,1/4.r,/ , tic v 'A.)4- L. 12ss0,--I
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above —
F Address
r
W
tL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4 (ci 120 i j Registrar of Vital Statistics \)0 C/vvrYNR,
(signature)
District Number 5 60 f Place • ` S 10l j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition II 119 li t Place of Disposition 'P�rVw ..,4,44Orim _
(address)
1
CO
(section) (lot number) (grave number)
+� All Q 114tr
Name of Sexton or Person in Charge of Pr miser ____ III
w b � (please print) .�- ,
Signature �„ Title �`'�m� i
(over)
DOH-1555 (02/2004)