Malone, John s • 3
NEW YORK STATE DEPARTMENT OF HEALTH liZ6
Vital Records Section Burial - Transit Perm t
Name First Middle Last Sex
io n I* L'\QI ory M .
Date of Death A If Veteran of U.S. Armed Forces,
3 -�7 I ] �e g War or Dates 1 cc5- 5g
F Place of Death _ Hospital, Institutpi p or I I Z t it f Town or Village,(e t`15 +-Q 1.5 Street Address l�t cn tat,3 t-to5p i+C
Manner of Death[ Natural Cause 0 Accident 0 Homicide 0 Suicide r7Undetermined Pending
Circumstances Investigation
G
AdMedical Certifier skNap - .f7" �' 1 A Title
dress
S R5
Death Certificate Filed --- District Number Re ister Number
c� Town or Village G'�S 1'�11� 6 bD ( qb
Date (Xmetery or Crematop;
❑Burial 03 _3 1 -- I-1 Y i )'1e ii(P,t D l.:,r`rlYtia 1
Address
Cremation D \kO J\b 11&
Date Place Removed
ZEl Removal and/or Held
•- and/or Address
Hold
N
Q Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
!1 Permit Issued to Registration Number
` Name of Funeral Home 13 rc.tR Y c 'z r& H7MI I n( Ca -/
z] Address * Mu .1ro' . SE I ( / Lai( • mi )CAef%n
!iiii!lj Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
4
( Permission is hereby granted to dispose of the human remains described above as indicated.
iiiE Date Issued 3I.29 1/ 7 Registrar of Vital Statistics j
g (signature'
District Number 5 Go/ Place 6 Cs r' S' t'ot I $, l•f Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- j�
WDate of Disposition 'l i3m(� Place of Disposition �puOuw Gr hvrsila..-
2 (address)
W
N
CC (section) // (lot number) (� (grave number)
CName of Sexton or Person in Charge of Premises L ra ) �L�
F (please print) 7
W Signature Ti-.4. tle OA74
DOH-1555 (10/89) p. 1 of 2 VS-61