Juchem Jr, Franklin NEW YORK STATE DEPARTMENT OF HEALTH 4 C L
Vital Records Section Burial - Transit Permit
<; Name First Middle Last S x
FR , (r 1 (—Middle
6 3 v c1 77 W►2 /78ZL
«' Date of Deat Age Veteran of U.S. Armed Fords
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3 Is J/ S7 yrt.s Dates Ai/�
of Death / ospita nstitution
.. City own or Village t if-Ai S / S Street Address L el.11 t,s
anner of Death Natural Cause 0 Accident Homicide ri Suicide nUndetermined El Pending
•; Circumstances Investigation
iii Medical Certifier Name ) Title ii
1 SC ►1V7drtir- rlof - C
AddressAi
er
,�//3 VC� ST , 9 (4gt44-- 0E-2kc�rr ,,,/" . / a (AS—
e.th Certificate Filed Distric ber Regis ber
Ci Town or Village �t,tr.")S F , c,
Date
Cemetery o remato 0 Burial 3 /1 ? 1
/( f.. t� V71 bzJ
Address
`:: RICremation u( U O7( - ev, Q U b`2�,�)s
Date Place Removed U /r `
2❑Removal and/or Held
k and/or Address
a Hold
Date Point of
g❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date I Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Registration Number
f Name of Funeral Home n ) � )7E�
>'� Address s..�2.►l �. �13X6�'C !-i.%�t�"Yt,�t C� r�lL C3I/ tly
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>'< Name of Funeral Fi Making Disposition or to Whom d i
Remains are Shipped, If Other than Above
Address
ti
Permission is hereby ranted to dispose of the human remains de ibed boy as i ted.
Date Issued a3/" ' j// Registrar of Vital Statistics j41,�
(signature)//
District Number S60/ Place % `ls , Ax
I certify that the remains of the decedent identified above were dis osed of in accordance with this permit on:
fr-
W Date of Disposition 3~(0•-li( Place of Disposition jot,0 ,.a C AttrOill,
W (address)
•
in
CC (section) lot numbe (grave number)
GName of Sexton or Person in Charg of Premises, �sr� 1.
z ?f� /I° (please print) 4
W Signature 7%19L„ Title at lh ii j 4R
(over)
DOH-1555 (9/98)