Foy, James NEW YORK STATE DEPARTMENT OF HEALTH
43.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
meE GER To
Date of Death Age If Veteran of U.S. Armed Feces,
EP j, 1 .q.01 ` '1 9 War or Dates go
M Place of Death (.,01.1\LS U G- Hospital, Institution orA n Rbtipn ck T1.( - CmLt KT(
-6i#y, Town or Village - k () -, Street Address u ft_5 i t r l4m t
ID Manner of Death r0 Natural Cause 0 Accident 0 Homicide El Suicide ri Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
0 CEAtq REALI
‘ lily
Address
100 Pfte_K , ) N S -FEU S ks?r L 6-(�t s -TA/ Ls 1-in )�'01
Death Certificate Filed -,----0LiDistrict Dumber Rster Number
Gity, Town sr-Village �6 S--%- cS---*
]Burial Date ����� � m
Crematory
(]Entombment 6 ` c2) c �' t Ni✓ I E ( Pc \04�1 lA IA( ,
Address
Cremation ( -, Q U AK6K Pita thEEKDSC',l.t t2 yin l a gO4F
Date ce R moved
Z Removal and/or Held
9❑and/or Address
i=" Hold
Cl)
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 0
Address
CI `rno Uv\ �-i� LA.KE GcoVZG-c)`r % taR-t-ks-
ig
Name of Funeral Firm Making Disposition or1'o Whom
} Remains are Shipped, If Other than Above
Address
t
ILI
t Permission is hereby granted to dispose of the human remains described ve as indicated.
igii Date Issued Registrar of Vital Statistics k,,d .A.: E
(signature)
District Number 66 5( Place i NS& tz C
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
iti Date of Disposition 4 UI 14 Place of Disposition P+AkUiA,) 6041b---
(address)
ttt
CC (section) C I/ry (lot num r) (grave number)
�I
Name of Sexton or Person in Char e of Premises c''1 ,- t^,v,tl
Z
/11.4 (please print)
Signature Title C1V(i411140�
(over)
DOH-1555 (02/2004)