Kennedy, James NEW YORK STATE DEPARTMENT OF HEALTH '` / '03
Vital Records Section Burial - Transit Permit
_ Name First . Middle t `/� Sex /
Date of Death Age If Veteran of U.S.Armed Fotces.
/
Z4 2.- 17 Si - Dates e--
.."-C4iarleawn
Death •.prtal, -titution
or Village �(-iT...„. [ du.S Street Address (Lu�-, S I ,4"t-L S
Manner of DeaNaturat Cause El Accident 0 Homicide 0 Suicide D Undetermined Pending
• Circumstances Investigation
Medical Certifier Name --- ��R Title
1. if 61d'x_i n_c._J( L-
Address U.�/1 0 ( C-(YL Q01-_,TEr-----< 2 UVu
.. '--.th Certificate Filed — District Nurfiber F)€ is er ber
MD own or Village L tf--'Z S.
a S.
nf-1 Date l Cemetery o r o
L_ ema l-Burial Z/Cam '17 /.J LT' Ur E>
Address
:: : 'Cremation (Jet_bti.._ V C4 v "---J�a AJI
Date Place Removed � "
0 D Removal and/or Held
F
and/or Address
Hold
IA
2 Date Point of
Na Transportation 1 Shipment
a by Common Destination
;:, Carrier
0 Disinterment Date Cemetery Address
ii: El Reinterment Date Cemetery Address
--.' Permit Issued to ,� lRegistration Number
Name of Funeral Home/;a1rara' V_ 'Baker Fwiel� home_ Of 13()
address /1 Lafa ttc (-. , bu.e.e ns&Lrj,)(Jut) L/oak- 1 d gO1
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
32, Address
a Permission is hereby granted to dispose of the human r. .-ns d 'bed abov as indi►- -- •
Date Issued O DI(k) a(11 Registrar of Vital Sta as - I ?,ems ` v /—C.
la
(sign.,:
:. �
District Number J�r!9CJ` Place
J � I G J
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I certify that the remains of the decedent identified above were • posed of in.accordance - this permit on:
f
E. Date of Disposition Z11((1 Place of Disposition �i ,v.,`J ,......
(address)
SUJ
la
(section) /7(lot number) c (grave number)
it
G Name of Sexton or Person in Charge of Pr miser2
rr�r^rt daa[
(please print)
Lf: Signature Title aZEPIRWL
(over)
DOH-1555 (9/98)