Bennett, Ernest „- . # 333
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 1 44,_iddle i Last Sex
Date ot Death Age If Veteran of U.S. Armed Forces,
- ( -- I'S 71 War or Dates
1-- Place of Death Hospital, Institution or
2 City, Town or Village I �r\UD L _ Street Address
0 Manner of Death'l Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined Pending
4� Circumstances Investigation
til Medical Certifier Name 1 Title
AddressVA/ �1 ikA' c
Death Certificate Filed ' ^ ', Distri t N mber Register Number
City, \or Village 1 r l ct, tAK� le 33 _3
['Burial DateqtNyeterytor,Cremato
['Entombment Addees
' cremation r; IA.-C-e.nShifuli
Date Pla a Removed
Z Removal and/or Held
2 ❑and/or
Address
Hold
O Date Point of
tTransportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i�t
Name of Funeral Home 1 1 kr— �rC,_. ;'VLJ..' I &mg
Address
1..0j37 1 1rily LA LarQ Ivy 12 42 -
Name of Funeral Firm Malting Disposition or to Whom
-- Remains are Shipped, If Other than Above
2 Address
w
P” Permission is hereby granted to dispose of the human r am described a ve as indicated.
Date Issued 41Z, IS Registrar of Vital Statistics _ iJ f, � a
(signature)
District Number c%33 Place I tot,)M1 b I rvi �Z
(G�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition y /i'1I1g Place of Disposition FNki..,d ( -•,-
(address)
11J
U)
IM (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Pjemises Al, '4f
Z (p ase print)
la
Signature Title (WM
(over)
DOH-1555 (02/2004) •