Rafferty, John F
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Namefi1r�st I MiddleLast Sex
V oRn "EQV-.iG1. �L IL
Date of Death Age If Veteran of U.S. Armed Fames, �
01- �3-col(e . `b� War or Dates I &5b- 1q \
'.a. Place of Death rr ,— Hospital, Institution or- -
1.1 Cit Town or Village v1�h 5 Street Address t l'\�! '\1\. .5 11b wo.&�tr. *
0 Manner of Deathatural Cause 0 Accident 0 Homicide 0 Suicide ri 0 Undetermined Pending
i Circumstances Investigation
ui Medical Certifier Name `J r- Title
0 `e\e-C\(\C., \\-0A6S \-J
Address )''''.0r, \r\O ). -)'C\ Cc c, ), \
D th Certificate Filed District Number Register Number
.Cit Town or Village G�t•(\ �Co\\S
❑Burial `Date h 1( Cemet or Crematory
['Entombmentv` ' `b ��� \� \\Z) C '(�(\A�
Address
14Cremation ' QV0. - r‘�� \y
Date ' Place Removed \
Z Removal and/or Held
fl❑and/or Address
Hold
to
0 Date Point of
ftQ Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Date Cemetery Address
Q Reinterment
Permit Issued to M Registration Number
Name of Funeral Home "\ �`X
\- Safi \ 2_ oor\ ,
Address y�
V* � r'l&h '(C...k ' G`2v\S t-cy,y..b !Jy \1`do3
Name of Funeral Firm Making Disposition or to Whom
1 . Remains are Shipped, If Other than Above
2 Address .
r
Ili
Permission is hereby granted to dispose of the human remains described above11 as indicated.
Date Issued 1 ) )2c`A Registrar of Vital Statistics U3�,\,ry W
at�`\ )el
(sign
District Number e i0 ) Place 6 s Fa. C is/iv V
, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Place of Disposition �i?1 (�t''�^irtc ri
LEI Date of Disposition i l 21�/�
2 (address)
Lk[
C (section) j(lotnumber) (grave number)
ci Name of Sexton or Person in Char a of Premises ('P,,, �. S
z (ple se print)
t Title (WO Re
Signature
(over)
DOH-1555 (02/2004) •