McCormick, John NEW YORK STATE DEPARTMENT OF HEALTH
2
Vital Records Section Burial - Transit ermit
Name < rjrst. iddle L t S x
Date of peath Age If Veteran of U.S. Armed Forces,
IO + c -. 1 aO 1 r., 1 c War or Dates
Place of Death Hospital, Institution pr , �
W Ci , Town r Village ik..Q .Q/IS Street Address Cc �r
CI Ma eath'Natural Cause ❑A i nt ❑Homicide ❑Suicide El❑Undetermined ❑Pending
US Circumstances Investigation
uj Medical Certifier itle
pe <!\ ,c.� Tv r• -
Address_ ji
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Death Ce i icate Filedttnimellre R gjst r Number
City�Tow r Village �.1�� 1
❑Burial Daie/�>> eetery or Cremat
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V 1 ' ^�0r����ir
['Entombment Address
: 4remation Q UGja' (2c.3G.A., i 0 LL—'o - In-1
Date Place Removed
Z❑Removal and/or Held
2and/or Address
F" Hold
to
O Date Point of
ti❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration tuber
Name of Funeral Home MA5* futdifIAL idloNliE 5L
Address
I £E6 Sr fOgt R 10 I`i1- 1.)S0
<i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
it
tU
P' Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued \°t)1 ,.,Registrar of Vital Statistics c C R-t
(signature)
District NumbPlace 0L •
I certify that the remains of the decedent identified above were disposed of in accord-41 with this permit on:
2
til Date of Disposition /6f t'j, Place of Disposition fntUv,-+ C °(4-
2 (address)
LEt
U,
CC (section) (lot number) (grave number)
p Name of Sexton or Person in Charge f Premises
�f;t �" ��^�!
2 (pease print)
//
• Signature (� Title CUE Mili
(over)
DOH-1555 (02/2004)