Schumaker III, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i'"'>= Name First T Middle Last J 1 Sex M
lr J O\n n floc SC_\n v a u \Ne Y
;i Date of Death c� I Age I If Veteran of U.S. Armed Forces. . . S
- Obi CA )cOltil I �.g CI 1 War or Dates e
14. Place of Death i Hospital. Institution or ��� i\�V City, or Village Guens�C'�i a f,> 1 St eet Address leleaCt
Manner or Death, Natural Cause El Accitlent 0 Homicide 0 Suicide El Undetermined fl Pending
t Circumstances Investigation
ilkMedical Certifier Name `. G- 1 Imo I Title �b
t
44
Address
102 PC/AA_ St. Gb2(-1s EctAxs , /V,--/ l Z.W)1
`<_ Death Certificate Filed 11{ District Number �/ - i Register Number
r:. .: Villageenjourj I (O;' 1
=:;<: City.� . . •r I Ci.l7
Date I Cemetery or Crematory
QBurial i O 1 10 I aQ)L.0 I -Pine. Utc &evnerk
I Address IA Cremation) a Y LoV `uyvi , aee ns\our. N1 l2- O f -.
1 Date _ + Place Remied
2 — Removal i and/or Held
f—and/or I Address
151 Hold i _
i Date I Point of
1i Transportation.; : Shipment
FS by Common Destination - - •
Carrier
Disinterment Date ; Cemetery Address
Reinterment F Date ; Cemetery Address
= Permit Issued to _ I Registration Number
Name of Funeral Home ,0r ; ? `,r,;- - N
_ 1 CI i/SO
Address `!
I / t
EP i t�1.;G D=1 L- Te J: l \<<%c� C U L l 2-e. ./‘; l LC -
Name of Funeral Ftr'm Making Disposition or to Whom ' I -
Remains are Shipped. If Other than Above `--
Address
»: Permission is hereby granted to dispose of the human re de bo s i ic ed.
> - Date Issued B--I 0"I(P Registrar of Vital Statistics
(stature) i
District Number j(9c Place titlesc p
1 (
I certify that the remains of the decedent identified abo were disposed of i .ccord.,ce with this permit on:
wDate of Disposition g(dli/, Place of Disposition i .I u-� ,
2 (address)
i;l,
tr.)
t (section) (lot number) (grave number) -
0 Name of Sexton or Person-in Charge of Pr mises ti. ,St rot
(please print)
LJ „�Signature Title aballirli.t
(over)
DOH-1555 (9/98)