Hammond, Phillip r_
5-76
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
iin Name First /J Middle a /Last Swi
MU-1P � , ri/1 o neUC
Date of Death G
Age If Veteran of U.S. Armed Forces,
`7 I2Li 1/2 7 / War or Dates "Pr
f Place • Death \ Hospital, Institution or
Ci , Town •r Village (/v 2 l ,6 3 dal, `7 Street Address O 2 7 /0-)"5 Tho-,
Mann- o Death'
Natural Cause ❑Accident ❑Homicide Suicide D Undetermined Pending
Ili Circumstances Investigation
Medical Certifier Name Title
/C.019- L- -8b7, ili .6 .
Address /���� ZP Q�
Death cate Filed �G District Number / O Registef uber
City n ow r Village �grWI rATS(3 Ut2 Ci (� /1m
El Burial Date Cemetery o Crematory, /l
['Entombment7�� �� 1 ' A)1yr o f 0-,)
Address f /) _
Cremation 0 u 9-,�6�1,� �(�J Q o Ais 3(,14-f. A7
Date Place Removed
gEl Removal and/or Held
and/or Address
i=" Hold
f
0 Date Point of
Q Transportation Shipment _
Ls by Common Destination
INi Carrier
Li Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iM Permit Issued to %� ►'� 1 U/� Registration Number
Name of Funeral Home ! 157Ge ...)(14/7 0 //r Z)
Address Q / 2-\s n�.1S.Q '� /V / FL d C/��
Name of Funeral Firm Making Disposition ora t'o Whom
14 Remains are Shipped, If Other than Above
a Address
ii
Permission is hereby/granted to dispose of the human remains des ibed abo e as indicated.
Date Issued 1267/ Registrar of Vital Stati ics / 6 77.7
(signature)
District Number 570 66 Place Oakr?7,-e -6c `
I certifythat the remains of the decedent
edent identified above wclre disposed of in accordance with this permit on:
2
Uf Date of Disposition 7/27/17 Place of Disposition ?1)1Q,/i I e__/".4., ,itl�y
(address)
iii
CC (section) (lot number)
(grave number)
Name of Sexton or P o i Charge of Premises �1►a►-1 CUe•-ve lcct
(please print)
in
Signature Title Lre e,-4,--
(over)
DOH-1555 (02/2004)