Jordon, Calvin NEW YORK STATE DEPARTMENT OF 14-7/7
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Vital Records Section Burial - Transit Permit
Middlec l l Last
Name 1tv(n \01(�� xtis 1€.,
Date of Death 5 II
Agq �j� If Veteran of U.S. Armed Forces,
War or Dates
J. Place of Death Hospital, Institution or
City, Town or Ville, Street Address
W.a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
s Circumstances Investigation
U.
ill Medical Certifier Name5cp() Title
qinkrciu MD
Address uuvorit
a €1, pm ,vl 13 Mf Mi
Death Certificate Filed DistricaVumber Register. u r
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City, Town or Village �?Lp®�
CI Burial Date A
gj,i e er vrerTD
❑Entombment Ce-ME):Ani
Cremation
Date Place Removers
❑Removal and/or Held
and/or Address
t Hold
in
O Date Point of
iL Transportation Shipment
Et by Common Destination
iiiiipi Carrier
❑Disinterment Date Cemetery Address
g ❑Reinterment Date Cemetery Address
ipPermit Issued to Registration Number
Name of Funeral Home fir` e &it,/ fit I( 30
Address
it Z t° . s . Qti z2 1:
t'� /1/1/ 1
Name of Funeral Firm-Making Disposition or to Whom T ,/� 1E '/
• Remains are Shipped, If Other than Above y not ellyy��, ,rJS .l er a I 170,11
;'; Address
ua
4 Z�� elfP, .�,rcey, a� ?ail s.41- , /1/��/ SII
` Permission is here y gr nted to dispose of the hums emai escri ed above , ,icated.
Date Issued Q R �� /� Registrar of Vital Statistics r e4i 4 6,
(s- nature
�nature
Nii District Number 66, / Place
1
I certify that the remains of the decedent identified above were disposed of in accordance w h this permit on:
k
Iti Date of Disposition -10 -C i Place of Disposition RileL1 L) C reivySGs.uai1
(address)
in
eltr (section) (lot number) (grave number)
• Name of Sexton or Person in Cr.rge of Premises I iw%o41,7 (3'vne((C
i ` %.1 ,� (please int)
Signature lit / Title Cftiui^�, A
(over)
DOH-1555 (02/2004)