MacDonald, John NEW YORK STATE DEPARTMENT OF HEALTH -" • I If 1 t
Vital Records Section Burial - Transit ermit
Na At /� (/'� Mid�c({)l�p(Q_ Last (Sex
Date of Depth ( • A If Veteran of U.S. Armed Fo rces,
f `�C.) C) War or Dates J IL` l —L
(13
Place of Death Hospital, Institution or
ZTo City,Tor Village( t� � �j Street Address
p; Manner of Death MNatural Cause 0 A id t 0 Homicide Ei Suicide O Undetermined El Pending
LLt Circumstances Investigation
ui Medical Certifier) NameY C) 2 -(---)t t 0 C.Ti_tle
Addre v
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Deat C rficate File Dist N n ber '\ ter Numl5er
Cit To n r Villages (1��
OBurial Date ( metery or Cremato y
[]Entombment r ( �`� "�� �i �Q_l)(�Q v,) CtNI`k-'CS1--j
Address {'�
•_.::i Cremation - r JU `' \J
Date Place Removed
�
ORemoval and/or Held
Address
and/orHold
0 Date Point of
t O Transportation Shipment
O by Common Destination
Carrier
O Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to L Registration Number
Name of Funeral Home Otosplo, I ul4 ti 1 oil°
i> Address
5/4 0 it (Q ' IQ lid`
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: Address
c
In
7. Permission is hereby granted to dispose of the human rem ins described abov as indicated.
Date Issued a L a 1 Registrar of Vital Statistics C-1._C aC
/ (signature)
District Number Lo Place 0 L. j f a � Q>C .
I certify that the remains of the decedent identified above were disposed of in acco dan►- with this permit on:
III Date of Disposition L#=1) Place of Disposition OP ,{ err q cc o_
2 (address)
LU
U
1C (section) f 1 (lot number) (grave number)
pName of Sexton or Person in Charge of Premises fi
Z /y/:, ,i (pllease print)
Signature L C �+'�%Ay Title 4 ��
9
(over)
DOH-1555 (02/2004)