Lacy, James 40--, -. SI ,) . '1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'.„ Name st Middle �LaGsty j Se
Ames
Ei Date of Death I Age If Veteran of U.S. Armed Forces,
6Q_ /6- go/� ,/n a i WarorDates Ale
F- Place of Death I Hospital, Institution or
>2 City, Town or Village lJeu C/ ib Street Address 3 Roin-ea-
ILI
ici Manner of Death ,A Natural Cause El Accident El Homicide ❑Suicide Undetermined Pending
AM Circumstances Investigation
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Medical Certifier Name Title
2 /v,.,v 60%A/ ' PA
Address
AP-4/con) •� Aft/ /,g 8r-5<a-
Ni Death Certificate Filed1G ! District Nbgr� Register Number
City, Town or Village b l �� ��
Date Ce eery or Crematory
::•: ❑Burial U ?-/9 - . 9/? //1 ree Oeu3 Ere/m.414127
Address
Cremation C30e-.21)(7-4V1/. / )
'
Date / j Place Removed
2 ri❑Removal and/or Held
-.. and/or Address
t Hold
Q Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment
i Date Cemetery Address
Permit Issued to r 1 Registration Number
Pi Name of Funeral HomeEalcA/ c l- . 41-0Je0A/A/90.-17--- D c c if
ni Address _,S Q./ � - j I/ i/ / -&-1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
0X Address
Iiiiiig Permission is he eby granted to dispose of the human remains,described ve a tfndicated.
Date Issued nit Registrar of Vital Statistics .
(signature i_J
District Number Place /0 lOr'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- _
W Date of Disposition gizo l o Place of Disposition '�'pp nt,U"`, eq��
2 (address)
uJ
U)
CC (section) (lot-number) ti4 rave number)
Name of Sexton or Person in Charge of Pre isesca rir j (�+.
z (please print)
W Signature it rc' Title (-14 MOB
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(over)
DOH-1555 (9/98)