Dwyer Jr, John NEW YORK STATE DEPARTMENT OF HEALTH �'� N 7l2
Vital Records Section Burial - Transit Permit
mi Name First + Middle . Last Sex
J1 \ Jo Se.ph b Li.m.e,c' c: (-. tLAci.L.
i,i'< Date of Death Age If Veteran of U.S. Armed Forces,
f V,ccr XN V)) , aot1� $(} War or Dates N 1 A
:ifA Place of Death Hospital, Institution or -�--
Aiwa,own or Village Gi e %&- �d 11 S Street Address 1 r1 e_ '71 r
► Manner of Death Natural Cause D'Accident Homicide 0 Suicide Undetermined Pending
7 Jal Circumstances Investigation_
.113 Medical Certifier Name Title
Me\'�SSck -ec\ ,�� ti\i
Address CA
nn / ,�1
v\ Carel (`v C)tPv"bv l y , r (moo y
Death Certificate Filed 1 District Number It Register,Number
City, own or Village el ier,s Fa\\ F^t\ 1 �
Date Cemetery or Crem Cory
x, ❑Burial d3 Zi 2O\U Tihe_ Vie; CreMcl'k'
...� `Addreaa-
Cremation Otka e.✓ RLI. &<(.i c..Q f1Stt./V� MCI. /,210/
Date Place Remo�ed
Z❑Removal and/or Held
and/or Address
Fg Hold
0 Date Point of
N Transportation Shipment
zs by Common Destination
Carrier
Disinterment Date Cemetery Address
0
Reinterment Date Cemetery Address
I Permit Issued to Registration Number
!! Name of Funeral Home fint1 \ ), -13Ka2 R-./a_49 .1 Atie-- 0) )-- Q
•:i. Address I
OM // 6> 16- C. (;)o6, ;,aS is U 2 .
11 Name of Funeral Fitful Making Disposition or to Whom ' !� / --® ti
-
PP
Remains are Shipped, If Other than Above r"
Address
_IN Permission is hereby granted to dispose of the human remains described above as indicated.
it Date Issued 3 11- . i Registrar egistrar of Vital Statistics
1 (signature)
Mif District Number 5 1 Place 6 `Qv S '\\ s N\-'?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
WDate of Disposition 3/Z3//, Place of Disposition - .i..(1c.� ( gteri.-
2 (address)
iti
U)
CC (section) A(lot number) (grave number)
QName of Sexton or Person in Charge of Premises k t; � ,SQ444-
Z �p (please print)
4:! /A Signature % 1 Title (UM VIM-
- (over)
DOH-1555 (9/98)