Venon, Claude a
/ /O
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'_: Name First ,a_u_�e Middle 1-i Last U ,n 0 Sex M
n
Date of Death Age If Veteran of U.S.Armed Forces,
I€ 2 1 1 5 1 201-4 q J War or Dates W w
.14 ce of Death
-; City, reF illage G 1 E'_t, S F ctu S Street Addres, 30 K e n s Q.c1
nner of Deatt Natural Cause Accident Homicide Q Suicide Undetermined Pending
lix �; Circumstances Investigation
ui Medical Certifier Name Title
0. E i `eer1 Sp(nej\ \ A L)P
Address
o1 Career uZdd , j Qa_. Q,rt o'bL..l , 1\x/ 1220'4
th Certificate Filed District Number O Register
rNumber
city C (ens �- I
OBurial Date
z1l �+Zo1 6emetery ot;Crematorit>
P1r\e_ \1tew
OEntombment Address Q
aCremation �&s .,Kra -_d,- / C- C (J L f.._)\ ,4N-1 12-pL-I
Date Place Removed
O Removal and/or Held
and/orHold Address
44,
C Date Point of ,
Transportation�❑ Po Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
O Renterment Date Cemetery Address
:: Permit Issued to Registration Number
`<` Name of Funeral Horne; (Saler Fier a.l j4,(Yt_ 01 i 30
Address
11 La layQ e_ S- . , aueens\oLkry , N e v.i `lot-1� 12 v
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
I
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Z f f 6 /' 7 Registrar of Vital Statistics LAJoW)-y\_,e j
(signature)
District Number 56 c 1 Place 6 (QM s f:o, 1 (3, f J ;i
iti I certify that the remains of the decedent identified above weream2L),Z4.1)
disposed of in accordance with this permit on:
til Date of Disposition sp y,Z Place of Disposition c%,f/4 6k)le?s
!J / (addre wJ
tii
fil
1:C (section)
CY
/' (lot number) (grave number)
ca Name of Sexton r e on in Charge of Premises i i� /' -v1 U '14.-c-4 e
/ (please print)
Signature %-�, °�'" �--' Title C Pema'6, , -
e
(over)
DOH-1555 (02/2004)