Higgins III, David 7-,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' Burial - Transit Permit
Name Fir Middle u Last Sex kil
AVt C) \ A1Mv f L1la61 or l
_.. in. Date of Death Age If Veteran of U.S. Armed Forces,
?-ll 7-01 la Z7 War or Dates
P e of Death stitution or
Town or Village Li j.2� ddress &-LlaI>/ iCi Ai-
0 Manner of Death L. Natural Cause Accident Homicide E Suicide 0 Undetermined �Pending
LEE Circumstances Investigation
53 Medical Certifier Name Title
N. DA1.,AvGitumA,.i, � Gor?- Ntiirs Pwaic, iI,)
Address
Its ��,-AA E r• A�aAV /QV
H
D--th Certificate Filed 'District Number Register Number
' Town or Village frtA LA t -A, y
■Burial Date etery rA grematorn
<< ❑E mbment �f''ZZ -"ZD1b _ Vs Pt1/ i (.J CA �A'TOrzi
Address (�j / •
Rilig remation _.�k. a)VAK�.1r.0 �-C vi4APQ,044/ , Pio 1-/
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
E Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
sii
Q Renterment Date Cemetery Address
l'iii .
<: Permit Issued to ` / wt { Registration Number
1/�Name of Funeral Home l L tf - 1�V rR-/i- i''J Awtti- 010-1 q
iiN Address,,
Z B,zo►et-bu.,-4 r® - .E0k,oft-iz-n _ICY 1:2-1
: Name of Funeral Firm Making'Disposition or to Whom '
Remains are Shipped, If Other than Above
Address
i
' Permission is hereby granted to dispose of the h emains. crib bove as indicated.
Date Issued 0&-la-Za 1 b Registrar of Vital Statis ' _
(signature)
imi
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 22 / Place of Disposition Pin 4._U i C/gym ,Y-Dsv
ri (address)r
0
(section) 1 (lot number) (grave number)
Name of Sexton P s in Charge of Premises �/i �.4 C -*? a,e
IP
z , (please print)
Signature V Title G/'e-mp,.iT/
(over)
. DOH-1555 (02/2004)