Doherty, George # Di_
NEW YORK STATE DEPARTMENT OF HEALTH.; _ .
. Vital Records Section iffrBurial.- Transit Permit
Name First,,/! Middle Las. Sex
Date of.Death / Age • If Veteran of U.S. Arme orces,
tt c' 1a t(o CU War or Dates --
- Pla a of Death Hospital, Institution or
Wity own or Village �L .-� .--_ Street Address CoL—- �i
0 Manner of Death Natural Cause Accident Homicide Suicide Undetermined ❑Pending
jW. Circumstances Investigation
Medical Certifier Nam Title
0. �CA^ kL,' ,AID
Address A '
>' D-.th Certificate Filed i-- District Number Register Number
m;:i Town or Village ;�,,,5 -�- c6e'i
«>'■Burial Date Cemetery or Crematofj� •
`t/11 /),ot�, fi,1c1/oc� Cre... r
r3 0 En,,,mbment Address
Oii Cremation u(ee^' .;-•" U. i • .
Date ) Place Removed
Z Removal and/or Held
C? and/or Address
1.77 Hold
Cl
0 Date Point of
Et
❑Transportation . Shipment
a by Common Destination
i Carrier
`:: Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
•
i Permit Issued to � Registration Number
• Name of Funeral Home c /. -r'5",.'rc ant t� 4-4-cl QD f y'(
Address Mi . --7 XN.2_,-,,_ Ave . .,.,/ eL-----mr
I aL
'<>? Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
$ Address •
12
.ili Permission is hereby granted to dispose of the human remains described above s in ' ed.
ni
Date Issued `f/I( /)- /6 Registrar of Vital Statistics 4� ./ /
(signature)
`s District Number c6 v( Place '1 d -f is e '
,:::,::,::
i.oHim I certify that the remains of the decedent identified abawilere disposed of in accordance with this permit on:
ui Date of Disposition Place of Disposition Eta VitJ C-ko.dfOrs— .
. (address)
0
r (section) A (lot number) covjor (grave number)
Name of Sexton or Person in Charge of Premises (1.�t
/ (p/e se print)
Sig Signature a — di Title a^E'i' i-
(over)
DOH-1555 (02/2004)