King, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Na�j First U.
� � ,�lliddle Last Sex
1rar N 1 nci AAA 1e
Date of Death Age eteran of U.S. Armed Forces,
O p t (Q - LD 1 LP S 1 War or Dates )1j 0
#- Place of Death Hospital, Institution or t
w Cite-of or Village 3oh n5bk Street Address A4a,ro mac,, 1r► CoUna A
/ f' l ,11 .
Manner of Death®Natural Cause Accident 0 Homicide Q Suicide ri Undetermined Q P'ending
t Circumstances Investigation
at Medical Certif Name Tale
0 1ar,n Liarrrrl &+on
0 O gthddrebsjrsce)A7
4 c3
Death Certificate Filed ( Distri Nu R9�i t r Number
City, Tow r Village]p hn5 btu. 5 pf
❑Burial Date metery o Crematory
❑Entombment re laa I ao 1 le t ne- \1 e.4) UretaCci-Dr-y
Address
'Cremation U1Z.Q.( 5 101,l.4l j / 79,011
Date lace R oved
ZQ Removal and/or Held
and/or Address
H Hold
to
(= Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
:iiQ Reinterment Date Cemetery Address
Permit Issued to ]� y Registration Number
Name of Funeral Home K 1 i I le.r- �-�,� r e-t� ( 'mil Ve oi l io
Address /_ 35 / aGITt it 3D I f)G tech Let,bz /v`/ ! ZS+a
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t:
"' Permission is h reby granted to dispose of the human remains described above as indicated.
iN Date Issued F i 2 go Registrar of Vital Statistics .--_-___,4,4Qk��: -z4.,"SL-/
(signature)
is District Number545 Place'^
lO/vr �'� ah4s ''II �L�
''' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ttt Date of Disposition 6 a /(Q Place of Disposition /�h�v Qt,J(�rCy51�, , �J
2 / (addre s)
tit (((
CO
CC (section) 1 / /"((llot number) (grave number)
Name of Sexton e son •� Charge of Premises �1 t/ra-J4 �% -m e
z (please print)
ltt Signature r/`' Title 6-/e-,71 .1-0✓`
(over)
DOH-1555 (02/2004)