Marquis Jr, James NEW YORK STATE DEPARTMENT OF HEALTH ff
Vital Records Section Burial - Tr sit Permit
Name First Middle Last Sex
Tame c V i nc Mar U1's ..1= 1 ri_--
Date of Death Age If�an of U.S. Armed Fors,
OW In 1201u, 5 r War or Dates
I-, 5.14ce of Death I Hospital, Institution or _I
Cit , Town or Village /�rl s 1 //r ; Street Address 2 S Mu rC o GIG 4V i-t e
0 Manner of Death atural Cause Q Accident 0 Homicide 0 Suicide ❑Undetermined Pending
Circumstances Investigation
� Medical Certifier Name t,,/1 G�(� e I � � � Title j 1
0 1 - i -A ---
Address5 aro,c/ Slrcdf, W& ,rlard N !211'
I-ath Certificate Filed I District Number Y ,Register Number
e Town or Village b LiTiV S F1 Li,-S I ' o O / 3 1 0
■Burial Date U 0 '2O' ' Cv C9.v9ktery or Crematory /,
❑Entombment f.1 --- rm_a.,_Tvl
Address
ReCremation 4.1er Lu-ef.Cltbt✓V !vt_ _ Zg► t"PO '
Date Place Removed
a❑Removal ; and/or Held
and/or Address
- Hold
0
I Date Point of
gi Q Transportation Shipment
a by Common Destination —
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home C:kt r l t t C; I E L�, 7
C ► t3C .
Address c
11 L_(tictv0 � -+� . 1f (( i' ) Q tc( c 1 bu1 y i NC�-, c�:� ,< l'3 c.( )
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
IX
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a' Permission is hereby granted to dispose of the hurnaQemains ,escribed bove as in, , d.
Date Issued Registrar of Vital Statistics ,O,_ ,r�� A , 2
/ (signature)
District Number , 76,0 / Place , ,/4
I certify that the remains of the decedent identified above w_ e disposed of in accord nce with this permit on:
2
LUDate of Disposition 6 ,-2I-1 Place of Disposition p,v,e, I/ie j tr44 ,tv
W (addre s)
U)
cc (section) // (lot number) (grave number)
p Name of Sexto r r in Charge of Premises ,,)i.,,, / am,.._69�nz +i
Z►: (please pnnt)
iLi
Signature t'!/� —__ Title ice n'! l
(over)
DOH-1555 (02/2004)