King, Shelah NEW YORK STATE DEPARTMENT OF HEALTH i '•... 1 q73
Vital Records Section Burial - Transit Permit
Name r First Middle Last Sex
, ,he la k lc.) ,ic. � �}ale. .
Date of Death Age If Veter of U.S. Armed Forces,
le?,—F) /J/ n , War or Dates (/n
p•, Place,a_Death Hospital, Institution iotr
City, T()or Village jOhn5bLi►'._. Street Address ]Tr, C- -v Ate'r i home
aManner of Death Natural Cause ❑ ccident ❑Homicide ❑Suicide El Undetermined ri❑Pending
MI Circumstances Investigation
W Medical Certifier Name Title
ntCI WaLt M1�
Addres
.i �G Death . ficate Filed District umber Register Number
City,(Town, Village)tm�-‘h c, kik. rot
❑Burial Date etery or�Crematory ,
❑Entombment / I — 7 1 ►' e v I L'A..t) 1.. ,iry1 k,fil)r
Address
-Cremation r= e .1 5 h Lk n
Date Pe Rem ed
Z❑Removal and/or Held
and/or Address
F" Hold
to
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to n � Registration Number
Name of Funeral Home I\-�'l I I 1 s'— ht vT ra 1 -1--kovnc 01 lei 7
Address ..J / 504.c. Eh 3() hici Laill 0 ..fkkA,y /( iJ
1,1h1 Name of Funeral Firm Making Disposition or to Whom
! Remains are Shipped, If Other than Above
2 Address
Cr
ltt
P" Permission is hereby granted to dispose of the hums remains escr' a as Indic• •.
Date issued _ Registrar of Vital Statisti
7% (signature)
District Number c . Place t� \i--Ni\..SV) i g►�1
1
I certify that the remains of the decedent identified above were disposed of in accordance is permit on:
k
IW Date of Disposition jLI 1 i i I, Place of Disposition i;ntus✓ �,a,,,r4cr,--,-
(address)
III
CO
CC (section) p/ (lot numb r) (grave number)
gName of Sexton or Person in Charge of Premises l Ft� (h��M'
2 (please print)
Signature Gl Title (Pk h'11'T�__
a:i (over)
DOH-1555 (02/2004)