Hoffman, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ni Name First � Middle. + I „,� Last Sex
(�0 CI . 'd 'I— �1�-1 a o _ A!t a I�
Date of Depth A e If Veteran of U.S. Armed Forc-"
C1 la-1 I l 73 War or Dates 0
4 Place of Death Hospital, Institution or
X City, ow pr Village I c 'i G Lame.. Street Address c ,l w rl.l
.fit Manner of Death W Natural Cdse Accident �Homicide Suicide �Undetermined Pending
W Circumstances Investigation
iii Medical Certifier Name. _ Title
0 V ir1Inia. J ,�r-
eno , s Cirpne-r
Address
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Death Certificate File District Number Register Number
City, Towel or VillageL0 n(; L. k, 5 (p
iiiiiii OBurial Datee etery or rematory
['Entombment �/ 3/ / 7 v)e `�'&I _ ' .1 1 .
nly
Ad
iiiiii14Cremation nu,knziotiurti., I v •
Date Place Removed .
2 Removal and/or Held
2❑and/or
� Addres•
Hold
0 Point of .
to Li Transportation _ Shipment •
C by Common I
Carrier
El Disinterment [...ilk: Cemetery Address
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Q Reinterment Date Cemetery Address
iiiiPermit Issued to Registration Number
Name of Funeral Home A4 L J f(Y lei 1er- / 'y Dl f q9
Address
(4;3`.-) 7 ANS kLe 30 iinci f a ki La k.k. pfklY AV—
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2. Address
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Permission is hereby ranted to dispose of the human r ains described above as i dicated.
Date Issued C Registrar of Vital Statistics
,c0...&(1511_,,
(signature)
lin District Number j,C Cp Place Lon G1 •.LaJ< , ! V`/
I certify that the remains of the decedent identified_J above were disposed of in accordance with this permit on:
p /�
pC11 1 i'� Disposition1 +r�0 (�wwfottd t Date of Disposition /0 Place of � a„/
2 (address)
tLI
C
(section) J (lot number) c (grave number)
ci Name of Sexton or Person in Charge of Premises C 4ru L J ¢"t46 •
(pl ase print)
.14
Signature 4l I� Title01W
(over)
•
DOH-1555 (02/2004)