Coon II, John NEW YORK STATE DEPARTMENT OF HEALTH # 13
Vital Records Section Burial - Transit Permit
Ra Name First Middle Last Sex RI��� Er\„0a�c� Cdb�
'' Date of Death ( Age ' If Veteran of U.S. Armed Forces,
Ol (>3 J vi to ( 9 3 j War or Dates N I>
Place of Death I Hospital, Institution or
ifi Ci ow or Village IA0c-ea.v j Street Address }3 Z UYnp'1 4 .r A« ts e
Manner of Death❑Natural Cause 0 Accident El Homicide 0 Suicide ri Undetermined W.Pending
Circumstances Investigation
8 Medical Certifier Name Title
MiCoel SYY (''a IA • L. ,
Address
iiiiiil Death Certificate Filed c I District Number Register Number
iliig City, own r Village �� \cXCci 3
Date •• 1 Cemetery or Crematory
❑Burial olci O ( a b1 Q ? \I i e UJ Cc e MCX bv1
Address n
El Cremation Q�� `r K)0, - 0.2e`I\S.V3‘.)f-1 / INN . I 2-60.`-1
Date j Place Removed
. 2❑Removal
2 ; and/or Held
ii!iand/or Address
Hold
O Date i Point of
•
Q Transportation. Shipment
0 by Common Destination
•
Carrier
Disinterment Date Cemetery Address
Reinterment Date ,Cemetery Address
`''. Permit Issued to _ _ Registration Number
iii!iii Name of Funeral Home _ _ _ . pK6� --z ,, ; -L ), Ke> 0//30
3 Address
g.: // 1._41 .4, ----- - 0 13- -") - c "a /vil y i 2.4F-0 I/ . .
`< Name of Funeral F m Making Disposition or to Whom d i
Remains are Shipped, If Other than Above
0 Address -
fA •
f
'<> Permission is hereby granted to dispose of the human r s des ' ed bove as indicated.
iiiii:ill Date Issued 06/O1f2oi( Registrar of Vital Statistics 11
... ( �� �signatur&)
?` District Number cap-- Place J/ttiL.( S� &J,iOkLS 0�-440(j/1 L ' A L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition C. I7IIb Place of Disposition f:rttUt.......- (n p...
2 (address)
Cl)
C (section) ,dot numbed (grave number) •
GName of Sexton or Person-in Charge of Premises • nip
z (please print) U
I: Signature Title 06"41-P4
- (over)
DOH-1555 (9/98)