Cook Sr. Howard NEW YORK STATE DEPARTMENT OF HEALTH # 51
Vital Records Section Burial - Transit Permit
Namg I First Middle; Last Sex
0 (-Oa rci E , Cop/` SR , Male_
Ail Date of Death Age If Veteran of U.S. Armed Forces,
1 1 - t3 -c2O I ) -7,9.. War or Dates / q'(p4
} Place of Death ] Hospital, Institutio or �rr- ri
l it , Town or Village C I e'15 a Ns Street Address fe ra i tS .kp i+a j
anner of Death i Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermin d Pending
'AiCircumstances Investigation
la Medical Certifier Name Title
p J ose,DK M ilm r 0 Nt1
as
Gl,Ase- � IISK
Death Certificate File District Number Registe um er
Effl `Cif Town or Village b)' ,1S "Gt 115 _ Jai
in❑Burial Date etery,orr Crematory
❑Entombment l 1- )1- 1 I A I ►'�Q Vie (Lr-f'trvIrk"1'��`2 Address \/
ilii !i /� t remation U,'lil )13bu rJ N. I
Date Place Removed
Z❑Removal and/or Held
and/or
f Address
t
Hold
O Date Point of
In Li Transportation Shipment
O by Common Destination
iEiiiii Carrier
Disinterment Date Cemetery Address
-
EN 0Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-b( f- 41,u yvArik j .Hy . ) fl C. 003-( 1
mi Address
c 't" Chu,)-Ch fit.: La-le Luzen-le� y fat`t�o
iii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address .
in
iii Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) I I i(o(apI Registrar of Vital Statistics (14 G 4 .2, LA).-A-"-cd-aZr
(signature)
District NumbeirbO I Place@ l of Glen c,i i Ls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l
t Date of Disposition jaov 2i i Place of Disposition ç?_,1)(bJ (tti*dTO,tuti
4 (address)
Ili
t (section) (lot number) (grave number)
• Name of Sexton or Person in Charg of Premises /rt r' Jt*Ate'
lease print)
111
Signature Title CQe"IdR-
(over)
DOH-1555 (02/2004)