Henderson, James NEW YORK STATE DEPARTMENT OF HEALTH A 6c6
Vital Records Section Burial - Transit Permit
El Name First Middle "Last
Last S
i 19.J163'S / , /�epvt E1ZSv /V Zer
- << Date of Death A e If Veteran of U.S.Armed Forces,
// Y.-) ns • : 1. Dates
P of Death Hospital, I' titution
City own or Village Gj L L�r.-fs F�ZC.S met •ddress t&,y.S Foul
€ annex of Death Natural Cause ❑Ac ci� 0 t 1-1omicide -❑Suicide 0 undetermined El Pending
W Circumstances Investigation
tii Medical Certifier Name _ Title
CI 1-2 n/C. &`-S �o LLt ti c 6&-L. .e l
Address
/ D/t,61:0 &Th`_', C� r" F,,,,
�s, i mod/
Certificate Filed District Number Re ter ber
t City, own or Village Le L 15:--)S / ,,c
�v luriai Date Cemetery or remat i r
19'/ 1AJC- L)r r
...... Ent°"�bment Address qqA/f"
Cremation U /lam C 51-13:..aQ / e 6 C�'
Date Place Removed / ' /
1f.0 Removal and/or Held
and/or Address
in.:::. Hold
Date Pointof
3 Q Transportation I Shipment
by Common Destination
Carrier
`:::`' Date Cemetery Address
r Q Disinterment
r Renterment
Date Cemetery Address
-M Permit Issued to Registration Number
IA Name of Funeral Home Ho,/t1Q.0 d-i .--&i r Funec cL1 k .rr ,01-1 c-1 C1 - -;-.
?"' Address
I 11 la yit Fie_ s-V. , auxepsbu ry , NJ e yor 1_ 12 cis o y
<_ � Name of Funeral Firm Making Disposition or to Whom
... Remains are Shipped, If Other than Above
Address
Permission is h y ranted to dispose of the hum ins escrib above as i-di I, ..
Date Issued / gib[/ Registrar of Vital Statistics c < "-
(signature)
'- District Number 5--607 Place (7e4s / /:_c/ � 1 /
`:`` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
M.
Date of Disposition i 12 g 1 Place of Disposition
(address)
ILI
1M (section) /� (lot (grave number)
aName of Sexton or Person in Charge ises L r~�td1*1 r n�CN�C�
at ( tom)
Signature 7J-I _ Title e-a 04)41 of
(over)
DOH-1555 (02/2004)