Collom, James ft
NEW YORK STATE DEPARTMENT OF HEALTH e } 3 12-
Vital Records Section Burial - Transit Permit
Na ...rr, First Middle Last Sex
(.in�e5 �-- -� Col/pm male.
Date of Death`- Age. If Veteran of U.S. Armed Forces,
- 1—c2 Q/ (u 4-2 War or Dates J0
f-- Place of Death Hospital, Institution or
City, ow or Village )j z.-r , Street Address 3 L./,i C ii 6,
• Manner of Death❑Natural Cause ❑Accident ❑Homicide 4 Suicide) ri❑Undetermined El❑Pending
Circumstances Investigation
in Medical Certifier Name�� Title
ga lJ Edrnre . -P C.
Address
!? ro cI4 Pit (I' 111 JU 6C.o r�.e ,MI ►Z g
Death Certificate Filed District N bee Register Number
City, wnpr Village 1.L��.,,r.i_ L zLjyL (p
❑Burial Date f ete� Crem�at y
['Entombment Li _��-�� ,`P l l nC Y I e Lc.) L. � A
Addre `,� /�
FCremation J[E ,,sh �,( / v y 12, U�'
Date J Plac Removed
so Removal and/or Held
and/or
CZ Hold
Hold
IA
O Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home- ; ' �j t y}j in J )-4ory . ' v' L Oa;I I
Address
‘, 1- C hu rC h St tit--k L-UZLr kk n,/ 12-g4(A
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
ILI
Permission is ereb granted to dispose of the human m ns .scr',Jd abo ' dicated.
r �/
Date Issued . i�p Registrar of Vital Statistics ,r.(.(.. 4
ign to e)
District Number j Place TOurS � LaiL ,tzi
i_...:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
• Date of Disposition Vag, Place of Disposition 4IJ.J
ainooc,
(address)
141
CO
CC (section) numbe�. (grave number)
ci Name of Sexton or Person in Charge of Premises dlot
=f `)Ork
(else print)ta
/�
Signature el Title ( 1_
(over)
DOH-1555 (02/2004)