Combs, Morgan 1, r # y1
NEW YORK STATE DEPARTMENT OF HEALTH
I
Vital Records Section Burial Q Transit Permit
Name First Middle Last ! Sex ^
MU( axe o �-rh Comb c r ' ,
['::; Date of Death 1 Age i If Veteran of U.S.Armed Forces,
( Q t 1 c0 t 8" g 2 War or Dates --
Place of Death ' Hospital, Institution or
Z City.Ton r Village Coe v ri i Street Address 3 2_ IOC busty?
> Mann each Natural Cause Ac ent Homicide Suicide Undetermined Pel d g
I� Q Circumstances Investigation]
la Medical Certifier Name ("-a Title
CI 4 LG',) 4,1/4). 61,‘„,10 A) . .6. I
Address
I6 ( CAP, Qo c.Q1,,A" a. i o00,
Dea icate Filed `: ict Number ber
Ci . Town Village U�� B �ney C
QBurial Date 7Cemetery Cremato
l 9 /c - ri/J t 16,-3
❑Entombment Address Q
G
._Cremation U mC b� 3 U c "i 4 e U�. 7
Date Place Removed /
0®Removal ! and/or Held
r and/or ; Address
Hold
fil
O I Date Point of
por3 0 Transportation Shipment
O by Common Destination
Carrier
Date i Cemetery Address
C Disinterment =,
C Reinterment ± Date t Cemetery Address
Permit Issued to 2,g_kt,v,....Funeral Home ; Registration
Number
Name of Funeral Home
Address
J/ - as- . C U S Ai/ 12--cpO y
Name of Funeral Firm King Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address _-- ..
M
111----
11 Permission is hereb granted to dispose of the human remains described ab ye as indicated.
Date Issued 1Q ?i Registrar of Vital Statistics _____ C..-._._.q. „
(signature)
District Numbercbcm Place t 0 O-
I certify that the remains of the decedent identified above were disposed of in accor ance ith this permit on:
LDate of Disposition (P, kid Place of Disposition P„U,, Gra.fa.,.
mW.
(address)
Ca
IX (section) ti number) (grave number)
Name of Sexton or Person in Charge of Premises Irv�p�.
it i Signature - Title (pleas�print)(11>1i C
(over)
DOH-1555 (02/2004)