Hall, Henry NEW YORK STATE DEPARTMENT OF HEALTH l
Vital Records Section Burial - Transit Permit
Name First Middle Last S
eN ►2 8-6 W rfrr� l7",t�-'LL 0 if
Date of Deaikh / A e I If Veteran of U.S. Armed Forces,
I I ZS 2-O/ 6, or 9 1 r Dates GJ t j J
Pla e of Death 1 ospital, stitution I
CD own or Village 0(,tNs ,s Street Address Cc f J S ! ,6-wS
anner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
1-1 Circumstances Investigation
Medical Certifier Name Title
(.2 ae,,e Peu^0i7Z6'► ion -PhS i'G'a
Address n ,J
DC) �ar� S'--r-ee PI-eriS i A\\s, 01 12-0
Death Certificate Filed /T District Number ` RegisterNumber
ity�own or Village ID,eV\s c(�\\� �0'i
Date Cemetery or Crem tory
:>: ❑Burial 01 z1 I-P-o 1u T;r1 e Cup enema or
Address t
::::: [Cremation MAauf- (ZC� C''v. Yvsio0� ; 1J 12- o - .
ZDate i Place Removdd
• 0 ❑Removal I and/or Held
and/or Address
= Hold
Q Date Point of
N0 Transportation . Shipment
5 by Common Destination
Carrier
Disinterment Date I Cemetery Address
Date .Cemetery Address
El Reinterment
iiiiiii Permit Issued to _ _ ) I Registration Number
>< Name of Funeral Home _ 1R13X4vt_ �,,��G63 c. ANC- I 0/j 39
': Address /
it L i L7 i L" %, i 0�:2:.uS i 3 i' �U . - i/
NaName of Funeral Fj'm Making Disposition or to Whom i `
Remains are Shipped, If Other than Above
1111 Address
EL
Permission is hereby granted to dispose of the human remains described above as indicated.
iiig Date Issued i( 711 ,2_nt 6 Registrar of Vital Statistics U -) C�'�t y`Q` l� `
Z'
/iR
(signature)
Il District Number 5 CO ( Place 6 (_ tr 5 l� k 1. S , f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F^ ► i
WDate of Disposition I!tS 116 Place of Disposition fig viw 0+0,40if4-
6 (address)
LJ
cn
C (section) //?// (lot numb r) (grave number) •
CName of Sexton or Person-in Charge of remises • LNP,at 014
z
/1� (please print)
W Signature (/`- Title rI' 111 'f
- (over)
DOH-1555 (9/98)