John, Henry a- 1
• I • ii I/19 t>NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
R: Name First 1 Middle Last Sex L jt
-3.--0
Date of Death 1 _Th ‘ .1, 1 Age c 1 If Veteran of4J.S. Armed Forces.
W.CI I 0 ) i ID I ('it
or Dates 1
Place of Death I Hospital, Institution or i L
City own y r Village llic.z.(\&\4z)o-,---i 1 Street Address `TO,-) C_osr,•(-\
JiL)
t2 Manner of Death Lir—I Natural Cause 0 Accident 0 Homicide 0 Suicide Ei Undetermined 7 Pending
Ilj `—'Circumstances 'I Investigation
'4) Medical Certifier
la Name h i Title
a
q:1 IA n reW GICI)(Ne.)1r 0°1
Address
::.i:;::i.: 1401411 a5Y1 4-V - ry-P )2_EO i
pa Death •Cificate Filed I District Numb - Register Number
City.-roy_vja1or Village Q>)ePx\Slok.wy 'I 0 .
r...„ Date 1 ' Cemetery or Crematory
L_I Burial ()kid OliLl 2DILo J T-, v,a v eu3 CA.9,rno,-(1t6,r\i
Address
:::: U Cremation L_Qo ON tv SZr)(3,-e\ Coep,(\._c-\ou,ry , A..) 1 aB 0 L.) _
, -
.::,
Date Place Removed
g 7 Removal . and/or Held
ill`—'and/or I Address
Hold .
0i) .
0 Date . Point of ..
:•can,ri Transportation . Shipment
a by Common Destination •
: Carrier
Date Cemetery Address
::: J Disinterment
Date Cemetery Address
:-:-: Reinterment
.-
Permit Issued to I, Registration Number
' --)) i
Name of Funeral Home ._.. . .o.40-31 *--"C.,'.•J&Ai;-.)--7-. . .111-i Jr-- 1 0 i i 30
Address i ,---, „-
if L L:.)" OV--.1 i t-::- •"1--. (9 u61---,,s1 (A' L it , A V- 1 2Pc1 LI w
Name of Funeral Film Making Disposition or to Whom .-- ' I
c
Remains are Shipped. If Other than Above
Address
l!figi Permission is hereby granted to dispose of the human repa1s esc -• • - •41111as in ' ated.
Date issued (t-Le- I ID Registrar of Vital Statistics p - CA„.
(sign-
District Number 94417 Place /10La;\ 0 Oiktfg-It. 64,14
:::
I-:-:- certify that the remains of the decedent identified above w.i. disposed of in accordan wi this permit on:
ii Date of Disposition C it f/ Place of Disposition
2 (address)
III
fla
Er (section) 4ot.number.), (grave number)
0 Name of Sexton or Person-in Charge of Premises
C3 ti ,i IL- -It-A—
z A .- ii, (please print)
44 Signature Title Clik(14/4-
- (over)
DOH-1555 (9/98)