Hughes, Paul NEW YORK STATE DEPARTMENT OF HEALTH a
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
. ) )-,... y.--15-?
Date of Death. tAge If Veteran of U.S ed Forces,
7 s ) ) ) _ War or Dates
lM- Place of Death / .R Hospital, Institution or
ZCity, Town or Village i•''' ` ' '- ` Street Address E)) Ai.,. , ..,j
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
L Circumstances Investigation
W Medical Certifier Name Title
Ras),), S----t)��&,tip
Address
Death Certificate Filed _ District Number RRgister Number
City, Town or Village k_, '"' a ,.,..
❑Burial Date Cemetery or Crematory
❑Entombment P_ Y 1 ins- C.:: c- va-�-„-v,2
Address?) ) 9 ) )
remation
Date Place Removed
Z Removal and/or Held
2❑and/or
� Address
Hold
0 Date Point of
Sri 0 Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home i c•��.r,, f)•
Address
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3 (')v0.k-„ cz vc4�j v� )V `f / za'U /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
AI
111
9: Permission is hereby granted to dispose of the human r ins described above indicated.
Date Issued Registrar of Vital Statistics 41 ga,QacyC.y
District Number Place
1-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z ` �
al Date of Disposition 'V 11-�� Place of Disposition pist1yu� Gm,4tort,,,,,,
(address)
la
CA
(section) (lot numbe (grave number)
Name of Sexton or Perso in Charge of Prises r.A- t t a
z / ` (please print)
Signature G rU Title Cl a pt IW
(over)
DOH-1555 (02/2004)