Durller, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section �, I) g17
Burial - Transit Permit
Name First MiddleThA Last e
��
Date Death c �,� ,�_�f l l ley- ite
Age If Veteran of U.S. A med Forces,
(. 1 ^ 3 - ( g ` (7 War or Dates
Place of Death Hospital, Institution or
City, Town or Village V n y(.rr f f( Street Address f arr)5 hit Q Pci
Manner of Deatip Natural Ca/se Accident Homicide Suicide Undetermiae�d ri Pending
Circumstances Investigation
Medical Certifier Na Title
uT i aCY) Ma Ntt
Address
Death Certificate File Di trict um er R7ister Number
Cit ow •r Village n / Ur g
❑Burial Date �.,, q / C etery o`r�rematory �/'(' I
❑Entombment t ( J11 U ti "W " l e 0 `" ' ���/j
Address _/
�r Cremation �L TSA(I bl; r i
Date Place moved
ri Removal
and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
-`-' Carrier
- Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
ti Name of Funeral Home 4-Roorci Lty_- -k kjevp r ( / /A C 00a-i i
Address
a�- C hu.rr h s-- La ice_ i z89-co
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 re 'ns described above as i ' t d.
Date Issued I ! 5- ( g Registrar of Vital Statistics .
1\axdictiio
(signature)
District Number 56 s Place Sip n y Cre.e.-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06 f Ii Place of Disposition fr.di,j (,,r(or,—
(address)
(section) A (lot number) (grave number)
ili
Name of Sexton or Person in Charge of Premises `' t-,t
(p ease print)
Signature Title t °t-
(over)
DOH-1555 (02/2004)