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Jockimo, Louis
NEW YORK STATE DEPARTMENT OF HEALTH d ` ' ' 4 9 . Vital Records Section Burial - Transit Permit 35 Name First 0` Middle ,F.r ri C'` Last Je c ` � Sex iki h- Date of Death Age I If Veteran of U.S. Armed Forces, d 1 ZC9 / i LP LO + War or Dates \G'-i$ ,_ )etSc) Place of Death n Hospital. Institution or '/� :(tia)Town or Village 1 E�S \\ S Street Address `1 L Sk rYWJ n Pr i1 Manner of Deatht�li Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending �J Circumstances Investigation Medical CertifierLia Name Title Address ad \-\ .yet o,.. , `z .S �o.\‘SSo, /v� Z 1 g 0 I p Death Certificate Filed/, 1 ��- lsz� District Number Register N mber . ► own or Village tuns Pa.\` SI I L. q 1 1 Date Cemetery o ,.,emato El 1 o c 1 a IL t p i U i e CYVA4Oi Address / �, Cremation QvcLul-e R©Qd f v-ee_,(\ ��u n 1 Date Place Removdd� I ZRt� __ 071 Removal ; and/or Held 2 and/or Address Hold 0 Date i Point of N Q Transportation , Shipment 0 by Common Destination - Carrier ::: Q Disinterment Date Cemetery Address ::::: n Reinterment 1 Date Cemetery Address liiiii Permit Issued to _ I Registration Number Name of Funeral Home _ ?r!x. ,0s.�-t . 1 N I Q f j tap :'0 Address Il L. 4 j —. u ;xs 6 ur Iti 12.c--c' tf Name of Funeral F Making Disposition or to Whom r f Remains are Shipped, If Other than Above Address - Permission is hereby granted to dispose of the human remains described above as indicated. a Date Issued 9`Z.7 tA Registrar of Vital Statistics ( JC&'vp-.Q w_ _J J ' i (signature) U 1, District Number 560( Place C CQAnc F S,c►1/4-) T I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 6 Date of Disposition q 121/110 Place of Disposition ;,hat...., C »c ri.-.. 5 (address) iU . • C (section) (lot number)... (grave number) GName of Sexton or Person-in Charge of Premises • `�F4flr441 g (please print) 1 Signature V Title ' / id - (over) DOH-1555 (9/98)