Hickey, Joseph . bp-7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseth F Hic-Ke Male
Date of Death Age If Veteran of IQ.S. Armed Forces,
1- War or Dates psi 66— 7 Z
}- Place of Death Hospital, Institution or
CitylAi , Town or Village r j Street Address Z, (,p Ash Si-
0 Manner of Death f Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
10
tit Medical Certifier Name Title
O
Address
Corti, iAN/
Death Certificate Filed District Number Register Number
'« City,Cr-ror Village r ) 1,l+3,1
❑Burial Date— II -
l 1 ^ -7 C i y-1 ed '
or re ryc-rc rwifo
[IEntombment Addees I n9
Cremation l leen3 bknj NW
Date lace Removed
Removal and/or Held
t and/or Address
to�= Hold
0 Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 6 r r- f 1 ,1 1 Jo rn , Inc_ , ()nail
Address �z r , I Z8%
a�4 Ch u,rch St 1.O�.kt.
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
• Address
t
tI
"` Permission is hereb granted to dispose of the human rem ' s described bove as indicated.
iin Date Issued Registrar of Vital Statistics E / ../
(signature)
OH District Number ys573 Place T(...,) n 0..F_ r_) T r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
In Date of Disposition 4 iii in Place of Disposition ��,,V, — (.r„ature ,
2 (address)
0
C (section) A(lot number) (grave number)
pl Name of Sexton or Person in Charge of Pr ises r,rio Sam'tit
(pl se print)
• Si nature �,i�`w. Title MAIM,
(over)
DOH-1555 (02/2004)