Fish, Harold ,' r, 1.
NEW YORK STATE DEPARTMENT OF HEALTH t I 3.5
1
Vital Records Section Burial - Iransit Permit
Nam First Middle Last Sex
-Ia r o Id 6 h. h MCE'l�
Date of Death Ag If Veteran of U.S. Armed Forces,
i b-- I tp �5 War or Dates /\1 U
}- Place of Death Hospital, Institutioyl or,6 City,(fownor Village JO h,13/jI riI Street Address (( Tr i l/
/ N
Manner of Death® ❑-Natural Cause A6cident ❑Homicide ❑Su ❑ ❑icide Undetermirkd Pending
tii Circumstances Investigation
in Medical Certifi Name ` i e
a torrc, 4 r I Ill_ ! Ors ►' 'A
112 SIdr ?w 1 A No r', t Face K_
Death Certificate Filed 1 District Number 5 s Register Number
City(towntor Village doh 1 Sb.r -
❑Burial Date -) Cmietery or Crema�gy
❑Entombment 5 - 13 F 20/42 y 1't edLd C_i`e�
Address
®Cremation 6D/U-ek n 5b U y A
lac Date e Removed
Z El Removal and/or Held
and/or Address
L.is
Hold
0 Date Point of
11,5❑Transportation Shipment
C3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to A Registration Number
Name of Funeral Home A/I i 1Ie;r t-well{ / r ; OH n
Address C )35 1 AdY5 M b 30 &.1/a i L,t/ Ay /gr ¢�
g Name of Funeral Firm Maki rig Disposition or to Whom y
9 p /
I Remains are Shipped, If Other than Above
Address
Ir
LE[
Permission is ere y granted to dispose of the human remains describ above s. icated.
Date Issued (p Registrar of Vital Statistics 0 a.
(signature)
1-2-J5 District Numbe Place
J� /62/0n eyf OAMbu r
IH
I certifythat the remains of the decedent identified above were disposed-at/in accordance with this permit on:
Date of Disposition 6717(gv Place of Disposition fi"lL C
(address)
Ui
W
CC (section) pat u b ) (grave number)
Name of Sexton or Person in Charge o Premises
(ease print)
ItLt Signature Title `I't
(over)
DOH-1555 (02/2004)