Hall, Jason NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section p . N Burial - Transit Permit
iin Name First ..T6 ./ Mi I;I ., Last J/ ;,/3
ii Date of Death Age If Veteran of U.S. Ar ed Forces,
��' e/� War or Dates
Place of D-ath / Hospital, Institution or � ��
�:>:.: e
City, own •r Village A9 j//� Street Address /O I('
ri Manner of 'eathp Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined El Pending
f Circumstances Investigation
El Medical Certifier Name i,vi Title
Address ! , a. i/
lBri
74. ..arl-,, 4'
Death ificate Fi ed Distric Number ' 'R�glster Number
<< Cit , ow or Villag�a ti�'4L 4"
Date , 2netery 9r/Cremato
❑Burial d' - 0` .- ioil V
Address
iii Di Cremation
Date ' Place Removed
Removal and/or Held
--, and/or Address
a Hold
a Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
liiiiiiii Permit Issued to A Registration Number
iiEEEiEE Name of Funeral Home w , ' 0//36
isi Address �`~' %��
i // (,_. _ - izoK
Name of Funeral Firm,M king Dispo . n or to Whomit ��
Remains are Shipped, If Other than Above
al Address
in Permission is hereby granted to dispose of the human retj,ins described a as ndicated.
iiin Date Issued71:-A3-4?)/7 Registrar of Vital Statistics 44 ,0,4,4
(sig re)
District Number 6� f Place �iy�.�t,,.A /� 2 7
::::. I certifythat the remains of the decedent nt identified above were disp sed of in accordance with this permit on:
,'II //'�
5 Date of Disposition g�li;it( Place of Disposition i,��l° 4I / (,r itmp1 4ro,vn...
(address)
W
Cl)
4 11 (section) Oct number) (grave number)
Name of Sexton or Per n in Charge of remises e; or ,A-tdt-
F L/ s _ . (please print)
UI Signature , _ Title C1112 O thle,
(over)
DOH-1555 (9/98)