Harding, James NEW YORK STATE DEPARTMENT OF HEALTH -. •___7
Vital Records Section Burial - Trans! Permit
Name First Middle Last I Sex
je"P C, 44 G I-d 1 n M
Date of Death Age J If Veteran of U.S. Armed Forces,
0' 13 o 12,01 La Q 1 War or Dates
} Place of Death c- Hospital, Institution or
�, Town or Village 3C�ra4-oqa Sfr iNS Street Address QQ,v' �6(_�� `k'i,00 p+-1-4 )
Manner of Death Natural Cause 0 Accic1eint ❑Homicide Suicide Undetellnined Pending
{" ►"t Circumstances Investigation
• Medical Certifier Name Title
0 ZG Mf r- D
Address c�,
21 C U rc. h cS r, S of r-a4-c C J a (Z'8t,4p
ath Certificate Filed District Number Register N ber
' :' Ciyown or Village Skn 5r 1.07
Date Cemetery orurematory
❑Burial 0 Z.- C7+ - 7 ' Ls. .i n.Q. View C_.e.Ny- cx 3
Address
1J Cremation � _� ) I [z 1(0 9
Date _ lace Removed
. g Removal i and/or Held
IL, and/or Address
Hold
O Date Point of
gi 0 Transportation, Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a Permit Issued to _ Registration Number
Name of Funeral Home RP-Xtn i,)i,11.41-r, NC' 0//f3Q
s Address
I/ (-d "- S;. 00 >;.iSu r Ay
: /2 y .
Name of Funeral Fm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
) ;
3 Permission is h re y granted to dispose of the human remains scribed above as indicated.
: Date Issued 'Z. l � Registrar of Vital StatisticsJ2 { . -4-01Athulk
(sign�u-ree;)
iiiiii District Number Place c f(�(��"
ySA 5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
W Date of Disposition Z 13 /16 Place of Disposition �ntt) _' ((r►'ymuro(1+.1-
2 (address)
W
U)
CC (section) (lot number) (grave number)
• Name of Sexton or Person-in Charge of remises f�tV ,. Qv�»i(4-
d.- , (please print)
1
44 Signature Title rilMiVit
- (over)
DOH-1555 (9/98)