Mayo Jr, Frederick NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
eckricK -r 4 /Mayo ,1Q /v40.lf._
Date of Death I, Age r If Veteran of U.S. Armed Forces,
g CI y - 2.(? I (D (p to War or Dates J p
#-► Place of Death Hospital, Institution orujZ r
�Ci , Town or Village C le n s n I is Street Address G l e nS T a l I S Ii--c 1
• Manner of Death I1 Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermin Pending
W. �P-� Circumstances Investigation
t Medical Certifier Name Title
0
Address
ath Certificate File District Number Registpr N ber
Cit , Town or Village L I�-$S ra I I c , 'Co b I LA L
Burial Date Cemetery or Crem ory
❑Entombment D`�- 0(A 2 0 I CO 1 � '�- V' i o.) C re_��
Address
;Cremation Q LlF f 5b y
Date ) / Place Removed
Z Removal and/or Held
# ❑and/or Address
E=
a Hold
C? Date Point of
EL
Q Transportation Shipment
G by Common Destination
ffi Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to 1-i I Registration Number
Name of Funeral Home rcuoc r t Q rat 1 0rYi_ Inc 0O(:),)1
Address O_1 1A rC l`l St La16_ bk2-Q,4-ru. Ny R.841-(0
milil Name of Funeral Firm Making Disposition or to Whom
ice. Remains are Shipped, If Other than Above
• Address
M.
• Permission is hereby granted to dispose of the human re ains described above as indi ated./
Date Issued C Registrar of Vital Statistics )s'(7�...�'-z:'17 ?/ - 1,,.-02'-<'`,
?, (signature)
(. ;/^
District Numberve) Place - -}
I certify that the remains of the decedent identified above were ofisposed of in accordan with this permit on:
Ill Date of Disposition Y f (((, Place of Disposition efitai.,,/ Ctz)('l44...
(address)
In
tO
CC (section) /� (lot number) —
(grave number)
Name of Sexton or Person in Charge f Premises G i43 Ji""
lit
r (please print)
i Signature Title r4-
(over)
DOH-1555 (02/2004)