Lemon, Peter , -"V. it
NEW YORK STATE DEPARTMENT OF HEALTH
O
Vital Records Section Burial - Transit Permit
Na First Middle. Last Sex
eq-e_4,- Le-en O n Ma it:
Date of Death Ace If Veteran of U.S. Armed Forces,
1 — / 3-- 2-0 hp '- War or Dates /V D
1- Place of Death Hospital, Institution or
City,( owror Village L v- ' — Street Address 11 {1 -4-ke.i4/1fj- Id vQ
Manner of Death 4�Natural C use ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
kt Circumstances Investigation
ili Medical Certifier Name + /l Title
V rC 0'110 Ve 1nl11C 5 1.-orr) tu'.r -
dress
Lonc LQ, -\J\y
Death Certificate Filed i District Number Register Number
City, ow or Village yyl � jr'p I
El Burial Date 2 JJ i etery,or Crem tory •
❑Entombment J _ 13 1 C.0 ' ' ►' V If'.' �ji �.-f�na.,�cji.
Addees /
Cremation UA bl_ fir`/ •
Date PlacdRemoved
2 Removal and/or Held
1-1
and/or
Address�;;;
(1) Hold
O Date Point of
0 Li Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M 1 I ,(1- 1I .- jov 1011 1�
Address
635.7 S k . 3o I r t6L La., L izs
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
fr
lirti
"` Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued J 3 I (P' Registrar of Vital Statistics A-/-je)
' (signature) •
District Number AD at, Place 1 vt�r'1 Q, LCYLc Lakf2._.
••. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fi11.1
iii Date of Disposition I /Ic i(�; Place of Disposition Eau., Ct
2 (address)
III
til
CC (section) (lot number( (grave number)
ci 6h,�
Name of Sexton or Person in Charge of Premises ,.tc ihral" •
2 i(please print)
Signature a Title iiikaitarit
(over)
DOH-1555 (02/2004)