Cook, Leland NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leand S Cook kMuIt
Date of Death A If Veteran of U.S. ArmedForces,
1 -2-�(-Z.01 'IT 1r War or Dates
1- Place of Death Hospital, Institution or L Rd
1City, own or Village ( ( I ' Street Address 14-5 Io. r 1 5
Manner of Death Natural Caine 0 Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
UCircumstances Investigation
i Medical Certifier Name Title
(t'DR.� aMCI 2inl n AA
Adds
nr1(1 r _ ("or 1 yui-P w
Death Certificate Filed District Nu e ber Register Number
City,(`Toi4or Village 4 en I c
I
•., ❑Burial Date metery,9r Crema ry
['Entombment
2- -2 01(p 1 r'c V 1 e i3 .�i-t (Y U lOfZ Address
;'1Cremation LL6 . t 4)1
Date ace Removed
Z Removal and/or Held
C a and/or
Address
Hold
to
O Date Point of
EL r-i
0 Li Transportation , Shipment
p by Common Destination
Carrier
` ❑Disinterment Date 1 Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home '( I`Jet' 1,Y f Z( -TpilVi
I r) (r)TI I
Address
ChurCh _fit-. L-CtKt Lu'
Luurne Ny l2$ P
.„.- Disposition
Name of Funeral Firm Makingor to Whom
Remains are Shipped, If Other than Above
Address
I
111
CL
-. Permission is hereby granted to dispose of the human remains described above as indicated.
„> d ., s Ps
Date Issued ) -ZQ 1(p Registrar of Vital Statistics_.F `` . _1,. ,�
`"- (signature
District Number it ,' s' Place I? Ol,O n 6 Ibd k j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition fl i i l' Place of Disposition pdv ,y,-,A, e 4-c'y
2 (address)
Ui
tI
CC (section) (lot number) (grave number)
2 Name of Sexton or Person in Charge of Premises Jeirvty Sty,ce's
Z I (please print)
IW Signature /,., Title C�ft.,�tei-or
(over)
DOH-1555 (02/2004)