Johnson, Robert NEW YORK STATE DEPARTMENT OF HEALTH J
Vital Records Section Burial - Transit Permit
Name First Miildle Last Sew,
Date of Death Age If Veteran of U.S. Armed Forces,
0 ! 0 / (o (.o Co War or Dates V A)/(,�a a.,,_,) b 3
1— Place ofDeath Hospital, Institution or
5 City,gfown o Village 0 v iusl. Street Address a_ ��e- ' - J
Manner o Death Natural Cause ❑Acciden ❑Homicide ❑Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title n
la A,0,3 e Con...i., _
13
Address t^
C,.. k prtf-le.
Death ! ificate Filed Di ti�u er Reis �u,mber
City, own g Village �( Q sS g l
❑Burial Date f Cemetery o Crem orb ^ /
m ment ��� f _ r - J f ,❑Ento b Address
[ Cremation 0 U-131 L E.X- -- tIW."12 3 71 t�
Date Place Removed 1 A
Z ri I--'Removal and/or Held
and/or Address
Hold
O Date Point of
CL
❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
E Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 2 ok. 0 / / 3 Q
Address /
ery &I-I-L-1 C2 arv.,. .',6v14 AJ'' f'7 plc)
Name of Funeral Firm Making position or to Whom / /
Ir. Remains are Shipped, If Other than Above
2 Address
IX
iU
'` Permission is hereby granted to dispose of the human remains described above as indicated.
iin Date Issued I 0 t CM.CO Registrar of Vital Statistics
` (signature)
District NumCLoc Place t o , a-1 O t-,-2_52.._ `,
I certify that the remains of the decedent identified above were disposed of in accordance 41 is permit on:
� Date of Disposition /o f!y lib Place of Disposition en.i Vtlw C( -u i,
2 (address)
LU
to
cc (section) At"
(lot numbe (grave number)
Name of Sexton or Person in Charge of Premises 3t"4ifase print)
iLi ��� (1�M
Signature /.t h t Title
(over)
DOH-1555 (02/2004)