Mingo, James NEW YORK STATE DEPARTMENT OF HEALTH "IP
Vital Records Section Burial - Transit Permit
Name Fist Middle La Sex
,. /nines i /,eJCJ P
Date of DeathG Age If Veteran of U.S. Armed Forces,
G 7 - OC) O�- /P` 5'2.3 War or Dates ( P/ _ (CZcO
1— Place of Death Hospital, Institution or b 6k 54' ' QIrt,- '
5 City, Town or Village I s Cd vd,eK3 a-- Street Address ry j�r �`f.,,,� t"n �A� Oprf Tt`crae w ,U
p Manner of Death❑Natural Cause ElAccident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Aase Tile
C- r/1 M ci 5 VA e"S A in
Address
ea 76er 4Pi.� Pi" ici 109r• f3- 9y,
Death Certificate Filed 77 District Nym) r Register Number
City, Town or Villagec cnsd e r e a S•G
❑Burial Date Cepielery or Crematory
❑Entombment i 2 ,P-f)/4 r//U 4- Oleo &F` "1 A LPL' /
Addres9 /
jgCremation qu Q ') 5 bc>►^r Oty •
Date Place Removed
❑Removal and/or Held
and/or
�,; Address
Hold
tO
O Date Point of
firr) El
Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Home E f i)p -cL "/y roi er, ( J6niQ--- CY-4,57T
Address3 /
cAi )• a‘31 __ )--N 4,-- my iar70
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
to
a` Permission is hereby granted to dispose of the human rema' described a ve indicated.
Mi Date Issued 6/2/1 ►/v Registrar of Vital Statistics - \Z-'I`‘,.,p '- �
(sign e)
/District Number / L Place 1)
`j ( c
� ilfSes-v 0..E P-
I certify that the remains of the decedent identified above were disposed of in a cordance with this permit on:
IA1 Date of Disposition IIIZIif Place of Disposition IMV't✓ C,�rrn4q'ih,
2 (address)
ill
til
CC (section) 1 (lot num r) (grave number)
• Name of Sexton or Person in Charge of Premises h 3iw mil
* t� please print)
Signature L( Title C@�JI�(aV2
(over)
DOH-1555 (02/2004)