Parker, Joseph NEW YORK STATE DEPARTMENT OF HEALTH k /s-7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
J e S 1 N C., M.,-kk r M.,te .
Date of Death Age If Veteran of U.S. Armed Forces,
A-ag -I 9 War or Dates LA\bar
-. Place of Death Hospital, Institution or
W City,(,To w or Village�CAa k 9 Street Address 5 t.L C1i t .1i Qp IQ-CI
p Manner of Death 01,610 Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined J Pending
iii Circumstances Investigation
W Medical Certifier, Nanip Title
n 1rnV J o IP\n.5or. k PAC,,
Address
Cori /\4\ n,
Death Certificate Filed District Number ,p Register Number
City, ow or Village 61 191 4 c.--
❑Burial Date �'etery,o Crematory
El Entombment
�` 2 ti►nt V!F l .r'P. k/A-0Q
Addres
:. Cremation C I,t,E E',K�b�
Date _' Place Removed
Z Removal and/or Held
SI❑and/or Address
10
Hold
0 Date Point of
11 ❑Transportation ; Shipment
O by Common Destination
Carrier
❑Disinterment Date I Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to I Registration Number
e�+Name of Funeral HomL�1Q- rill 1-( Y} I ' C --i 1
Address Nuu- k a /o LIA. .e.rru AA( (Z4-142
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
IL
• Permission is here y granted to dispose of the human remains described above as indicated.
Date Issued 0i i ;Registrar of Vital Statistics &(,...i✓ /, y, .:t.,cf
(signature)
------
District Number -e Place S/s s � �,�,� +(&d� le
I certify that the remains of the decedent identified above were dispos d of in accordance with this permit on:
tu• Date of Disposition 31i/It. Place of Disposition .f 1 C'rm c?tt,X'li,,—
2 (address)
Ca
CC (section) , (lot number , (grave number)
2 Name of Sexton or Person in Charge of Premises (hr",.T- t°'1
( lease print)
SignatureZ
104.5 Title 11.6t2
(over)
DOH-1555 (02/2004)