Jock, Paul NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' Burial ® Transit Permit
Name FirstA Middle ,. ( Se
Date of Deat Age I If Veteran of U.S.Armed Forces,
Al-Deli
/2 9 Z I WarorD / .5 `fJ= Y
E Place ath Hospita institution o
City Town o Village ��}r Street s IN , yt_5,J CAL
0 Mannero(Death j}Natural Cause Acci nt Homicide 0 Suicide Undetermined Pending
'J� Circumstances Investigation
w Medical Certifier Name Title
CI fd"i/eJ2— CY92-S U iv
Address
,:*: 9 C,61-YL Ev*
_. 0 2515-A,CE UVLAI A-/ /. / Leo y
..,
f..,„: Death cafe Filed ict Number Rd ester umber
-`' City Town Village j ' s7,1.53 ',
❑Burial I Date / �7L� / Cemetery orCematory�
❑Entombment' / p,,,, r
Address n
(cremation e lr x,_ (0 Q d� 5-�(3 aL/vz /[/
"` Date ` Place Removed �'
Removal ` and/or Held
hi C (
and/or Address
I..., Hold
C)
' Date Point of
E Transportation Shipment
Es by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home L .�'1L - \ ;' & r \ Ho c c\ ( j\ -:\0
Address
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
• Address
M
itl
• Permission is hereby granted to dispose of the huma r�,aains described y as indicated.
Date Issued Iq 1 ao`, Registrar of Vital Statisticsc Y.. �\
(signature)_
<' District Number -i-. Place(U L3h 5 GLil_e_c4-,'
I certify that the remains of the decedent identified above were disposed of i accor nce with this permit on:
Z
al Date of Disposition 1(36In Place of Disposition S Nd ,,."-r. .,�,
a (address)
f
iM (section) (ot number (grave number)
Name of Sexton or Person in Charge of remises r.r . /A,�e11
2 (pie se print)
t . Signature II Title `/fir
(over)
DOH-1555 (02/2004)