Walker, John NEW YORK STATE DEPARTMENT OF HEALTH if 670
Vital Records Section Burial - Transit Permit
i
pl Name First Middle Middle -- Last d Sex til 011(1 . -v\i- '0.1,1C2r
,.....
Date of Death i Age .„, I if Veteran of U.S. Armed Forces
ciur ,
. N IL i ac , War or Dates Ir+rm/ 57_ 5
Place of Death % I Hospital, Institution or
City, Town or Village NI-...1r EAvievcC), 1 Street Address roc*- i-‘‘.. 4‘Stx-N
IS Manner of Death MI Natural Cause 0 Accident Ei Homicide 0 Suicide 0 Undetermined El Pending
Ili Circumstances 'Investigation
fil Medical Certifier Name 1
L Title A A )
a_,JI 67— lyn, sc li .j,,.. /vii ,
11 Address c, c
II.) a kAis
I Death Certificate Filed — , 16-I-Iia Number i Regi umber
City, Town or Village 1-„,c.\-- &Away-6 5755
Date CeaRtery or Crematdry
CI Burial CYA 1201 &ow) Vu-Nt \hew Clemcziorq
Address
DKJ Cremation (..f\ v .,,-
f..00.4 t--- C) ueer\S-vovt- , 1.3%•1 12.1SCI Li
Date Place Removed
gEl Removal and/or Held
and/or
Address
Hold
fi n 1 Date ._....
PcJint of
L..!(I) Transportation i Shipment
a by Common Destination
:-:: Carrier
e.:.
Li,--,Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home , 'Baiter FL-WC/cL/ tiOrne__
Of 1 c.)
Address
IN // Lara-ti ate (5f.• , (A c ,nsbury , )Jew t-k c jt_ I 6701
Name of Funeral Firm Making Disposition or to Whom
Sr• Remains are Shipped, If Other than Above
Address
M
Ak
Permission is hereby granted to dispose of the human re ins described ab e as i dicated.
li Date Issued CPC1-16) Registrar of Vital Statistics V-
(sign 9,1---
District Number 5-165 Place TIMM- 6-6 41-014Z, EdWaA-CI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition 11211/11 Place of Disposition ,et,t(L,- avalcetrYW-
2 (address)
ig
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cr (section) //r(il;ot number) (grave 4 a tr. (grave number)
° Name of Sexton or Person in Charge of Premises
0
z d ,- (please print)
94 Signature Title (IZEPI} Tia_
(over)
DOH-1555 (9/98)