Sherlock, Jerry # ST)NEW YORK STATE DEPARTMENT OF HEALTH
r au na = Transit Perit
Vital Records Section
s Name First \ Middle I ast Sex im
J-e,l'113 }r-1-h ur S Ir--rloc 1L 1
Date of Death 1 Age 1 If-Veteran of U.S.Armed Forces,
IS ()-1/if/2-01-4 1 `Q`Q 1 War or Dates Ic(P9 - [944
i Place of Death I Hospital, institution or
City, Town or Village ,e_2 0 S but\ -- Oh Street Address A-Ve
'in Manner of Death aNatural Cause D Ai ident n Homicide n Suicide 0 Undetermined Q Pending
u Circumstances Investigation
`' Medical Certifier Name \irtE. kiceTitle ittuto
in
Address y g -- S+. � jg Fa.E,� , ti y , Zoo l
Dea 9cate Fileck I Disict Number Re ister Number
1 City Town o Village l.Ls -rsd2 I �9,c') cl
`'.==❑Burial Date 0-40 /20 Cemetery or Crematory t/
Q
; Entombment I V QLO
:: Address
.::::
:>:-:4jCremauon 7 0E_C h \DLm Jv
'-' Datej Place Removed
. 7 Removal { ; and/or Held
and/or Address
Hold
r
.0 ► Date Point of
E oLiTransportation 1 Shipment
0 by Common l Destination
Carrier
- Disinterment Date 1 Cemetery Address
n Reintermant Date 1 Cemetery Address
Permit Issued to i Registration Number
Name of Funeral Home .. C.:`� . �L L��,•\ \ ‘.-NDc'c L:j j ?,0
''-> Address _
c<»
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
M Address
0
pet , •ission is d l hereby granted to dispose of the human re a s described above AS indicated.
II
Date Issuer C Registrar of Vital Statistics C,,,�_ j -
1 (sionelure)
it: C..-
District Numbe{� Place I, �� d- C �2-C r�S�
I certify that the remains of the decedent identified above were disposed of in ace.'dance ith this permit on:
Date of Disposition Th 1l' ! Place of Disposition fiV OttG, L to°`'
� (address)
(section) zillor number) (grave number)
0:
Name of Sexton or Person in Charge of Pr ises G ,,J -h+tit
(plea a print)
141
ff Signature G� Title ` ili"�
(over)
DOH-1555 (02/2004)