Hague, Jonathan g.
NEW YORK STATE DEPARTMENT OF HEAD ri * '8'QC
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'onl fiT NA AtI,AtS 1�/^*(0% tit
Date of a th Age If Veteran of U.S. Armed Forces,
10 /Z3 , i1 (00 War or Dates
1- Place . .-ath Hospital, Institution Rr
City, Tow sr Village CNAR1..E +� Street Address fi�1Z 30 A
Manner of Death L. �.Natural Cause Accident ❑Homicide El Suicide ri❑Undetermined ❑Pending
W. Circumstances Investigation
tu Medical Certifier Name Title
CM AIAZS c Sw A-2,'A . A'1 U
Address
QUM PAtfAc, A v e.. A- -reP 4'- . N`I
Death Certificate Filed District Number Register Number
City, Town or Village C144P. s1251Q 2 '2. .3
gil ❑Burial Date Cemetery or Crematory
10 )2Q,
I ►'1 Pi N E. t1 e� 2v
C ,4 A.-ro sii u�-c
❑Entombment Address
; Cremation Q(,t, gu,p a Y
Date Place Removed
Z Removal and/or Held
2❑and/or
F; Address
In
Hold
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home S (AtlitNtot (AtliAN 2 i�-I eQ uI1(tix, /444Z O i 9 t,,
Address 01 8A4 n
Ceoeul2Nr e N r��c�y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
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Permission is hereby granted to dispose of the human remains describe9ove as indicated.
Date Issued Ip/2tc I/7 Registrar of Vital Statistics ..c.-- .A C„_, .\—cs-\_
(signs )
District Number 2E472. Place —10(pi., or C44 r s-re N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
e
Z �
ti Date of Disposition /4 131 I r? Place of Disposition '1',t�,, ve
(address)
Ui
to
is (section) j/ (lot number) (grave number)
ea
Name of Sexton or Person in Charge of remises
iINAV
(p1 se print)
i Signature a 1.0 Title fibs-A ti
(over)
DOH-1555 (02/2004)