Campbell, Malcolm NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section Burial - Transit-Permit
Name FJrst Middle Last Sex
�Al Cohn OcCr/ haS AlY1 e-g • /VA/@_
Date of Death
Age If Veteran of U.S. Armed Forces,
�% O/i 8.g War or Dates /9'7L - /9 ��1 Place of Dea Hospital, Institution or
City, Town or Village S( }-1OiJ Street Address ,& C poi pd t// Ls A�t1
ilk Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Li/ Circumstances Investigation
la Medical Certifiern Name &Al-? , )
Title
Address
`-3 7 A 7' l.J A i €iu s 6 N'X' . / :2-s -Y 3
Death Certificate Filed / District Num r_ Register Number
City, Town or Village S Ch �A_) /s6_3
❑Burial Date C netery or Crematory/m
❑Entombment V/ / c2 d / // 11 i e/e4 (� e,eiP7 7
Address
.igit3Cremation Qd eeAls ;,+r v �'.-
Date Place RemdSied
Removal and/or Held
and/or Address
Lt Hold
LC
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to /, Registration Number
Name of Funeral Home W�i-c( ) k(/ re)Peyp/ //pv_ Oc s
Address n
J �roi 4A/4 N 1�� 74-
qg Name of Funeral Firm Making Disposition or t'Whom
Remains are Shipped, If Other than Above
2 Address
IX
U
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 6 f/),/.) ,/ Registrar of Vital Statistics 7)-te1 , 2-c E.
ure
District Number Place A)e6 6 F S J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LUDate of Disposition •Jj j Z j I M 1 Place of Disposition -19,ne�:i�,/ C,nm-.c{-0 riv,
W (address)
Mt
(section) (lot nu r) (grave number)
4 _ ,
0 ,
ta Name of Sexton or P rson in Charge. Premises n Tyner n4.40-
`l (Please print)
Signature Title 6RG fi 41-
(over)
DOH-1555 (02/2004)