Higgins, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Trans tiPermit
Name FirstMiddle S x
i Am trs
i-t) ,s .. ez,0
Date of Death 1 Age If Veteran of U.S.Armed Fines,t(�/ I J i E..� , . -.r Dates .
1- - -.,e of Death Hospita, nstitution or
own or Village C �,, r-Q't.L,g,. -- .ddress Oe- s- Fetz___.(--
a T anner of Death EfNatural Cause El Accident El Homicide ❑Suicide ❑Undetermined Pending
U Circumstances 1. 1 Investigation
W Medical Certifier Name Title
ifl
Address
th Certificate Filed/Th �"' District Numbe Register Number
City, own or Village ` S L ', ) / 2(e S 1 /Jc
Burial Date t Cemetery o CrematoryIf // 1 -- Pi A./Li- a&Lt.)
[]Entombment Address
Cremation U /U-s`f3 L1141 Al
Date ¶ Plac emoved •
Z Removal and/ r Held •
2❑and/or Address •
V} Hold
0 Date Point of
Q Transportation i Shipment
3 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date I-Cemetery Address
i
Permit Issued to Registratidn Number
Name of Funeral Home ckl noi.(8 , . 1;Cr` Rtne c a..1 1- _ 0 1 I `-i CI
Address
11 lct.- yQ ESA. , tz,�e nsbu,(y , Nicv-s 'Jurk_._ 12cio`--1
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
;' Address
Z.
ILL .
Q. Permission is he b granted to dispose of the human remains scribed abo as i ed.
Date Issued ddi Registrar of Vital Statistics 2
(signature)
District Number .5-69 i Place 64°4J AV)/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
it1 Date of Disposition `I` "1( Place of Disposition u Wk." ( r7rvi r+u I,“-
(address)
(1 ia
IC (section) (lot number)C (grave number)
CI Name of Sexton or P on in Charge of remises r.s � L— v t 1titr
L i(please print)
iii Si nature ? Title � '()*(0 Q,.
g `�
• (over)
.
DOH-1555 (02/2004)