Homestead, Herbert 3$Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name j Firs Middle Last Sex
r b it t (,,.c) 47 rVK fr 06� Allo le_,
Date of Death Age If Veteran of U.S. Armed Forces,
5-c?),. I - I Co U `t War or Dates Kij reayi
j- Place of Death , Hospital, Institution or
w it Town or Villag�ex)3 I L I Ls Street Address e y)CJ
O nner of Death 0 Natural Cause 0 Accident ❑Homicide ElSuicide 0 Undetermined ❑Pending
I t Circumstances Investigation
W Medical Certifier Name Title
12
Address
Death Certificate Filed/1 r— ,/ District Number Register Number
C Town or Village C-,ler 1-s 5( j 6, 6
❑Burial Date �j ll /� -Cmetery o Cremat
❑Entombment SA`) /L r ) ry of
� alI)v y
Addre _J
.,Cremation UU Q .4u)k LLr f\W
Date Place Removed
Z ❑Removal and/or Held
14— and/or Address
i=" Hold
ill
Date Point of
i 0 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 40Ir`�,L z,(.1p i� . //
Address LLi"( ) Lit La,,t-e_ Lti 7Lt_ A. ia,k;.,
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
• Address
Ir
IU
C3 Permission is hereby ranted to dispose of the hum‘remain escribe above as i dicceed..
Date Issued Registrar of Vital Statistics 7, '� d _.
(signature)
District Number ��� / Place ���_�
}.. I certify that the remains of the decedent identified above were disposed of in accorda ce with this permit on:
tki Date of Disposition 61/ilkL Place of Disposition IN�w t/c�nr+atol..
2 (address)
til
Cl)
CC (section) 4 Lot number) (grave number)
Name of Sexton or Person in Charge of Premises a., St '
/�1�, lease print)
Signature ( ., Title t 1i�t
(over)
DOH-1555 (02/2004)