Eager, Jacob NEW YORK STATE DEPARTMENT OF HEALTH * w :' 1 )
Vital Records SectionBurial - Transit Permit
Name First Middle Last Sex
J �oib Lev', E le-
::.:* M
Date of Death Age If Veteran of U.S. Arrr Forces,
011031 fib Z 1 War or Dates Z - Z D i 1
• Place of Death Hospital, Institution or
City, own •r Village , --r-h0. hi-i C Q b Street Address 'v ' i-acto R Q J
ui
Manner o Death Q Natural Cau Q Q Q Q Accident Homicide Suicide Urtfietbrmined Pending
Circumstances 7 Investigation
La Medical Certifier Name Title
14 �ichox1 5.11C1rfa_ /-1 D
Address 5-6
13(0 04 SA'. W6t4er ft)rd /)) I ait1(
Death ificate Filed District Number R gister Number
<i City, own r Village Sctic J h+ j Co ill(al yS
<;i QBuria Date q Cemetery or Crematory
❑Entombment 0 !� �t7 Pi rte VI ."AA) C rr-e IAA Gt D r i UA,-..+
Address
;'[]Cremation Q tr.CA k✓ ` 1,0, (`�t t-,e.¢..4.S/114 r N')l
Date Place Removed
gQ Removal and/or Held
it: Address
toH and/orold
0 Date Point of
Di Q Transportation Shipment •
FS by Common Destination
mi Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1 e A„1 b e 0 r LA SA-a+co rd F., OI yr I 3
<< Address /� J
$ 3 ke Rd, a u-eens Isar JQy ja3ov
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
It
lit
gL
Permission is hereby grantedto dispose of the human remains described above as indicated.
Date Issued t'AOS113/ Registrar of Vital Statistics ,t,� •
54_ 44, nri
(signature)
District Number to kot Place ago 'J0 1Iy31._ by. YYQ Jry S, Ov y 1 Zl Z/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
Date of Disposition 1119
10 lit Place of Disposition ��0� !r ti,W �
(address)
Ili
CC (section) (lot mber) / (grave number)
0
D Name of Sexton or Person in Charge of Pre es nl (`J` f 4'
(please pint)
111
Si nature Title 1L11,
9
(over)
DOH-1555 (02/2004)