Johnson, Nelson NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
N.aagie First Middle Last Sex
CAS an D Jahnson Maj-C-
Date o D th Age If Veteran of U.S. Armed Forces,
� R �?� `7 B 0 War or Dates 1 q g q., (o" .
• Place of Cleath Hospital, Institution or
W City(Iow�r br Village�phu C.rrJ Street Address 2a1 -1-4 ad lei/ Rol
0 Manner of Death 07 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undeteimined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Uhrts-}'Dker- "_7 M1b
Addres
(5u-12.e41sDI J 4
Death Certificate Filed District Number Register Number
City, r Village S-1 r j C & rj(0S8 Z
❑Burial Date/ meter\yror. Crematory'"'
❑Entombment b i 1 b 11 J l nL V 1 Pam) �.�rr ,
kyuc..1 G
Addre �J
,Cremation S b
Date lace Removed
Z❑Removal and/or Held
C and/or Address
H Hold
to
O Date Point of
n Transportation Shipment
l3❑
i
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home r e jy y 1-I- m . I VI C (Ma-/ 1
Address
al--- Niir 1 St- L Luzea-w_ Ny I z g 1-10
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
LU
L Permission is hereby granted to dispose of the human ains describ d bove 'cated.
Date Issued i 1 D 1 Registrar of Vital Statist' 9
1 (signatur
District Number /052 Place 1 (9 uYl q si o hy Chef--
:.:::,..:
"'" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu• Date of Disposition q Igo In Place of Disposition et ii,:.• lof•..,
(address)
U
t
Cr (section) A(lot number) (grave number)
ct
Name of Sexton or Person in Charge f Premises `"'�
(pl se print)
F Signature 4( Title t¢&m,t
(over)
DOH-1555 (02/2004)