VanBumble, Larry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
N me First Middl Last Sex
Voul 4u '
Date of Death Age If Veteran f U.S. Armed Forces
07- I C / q War or Dates 19(p ID-lei"
Place of Death 1 Hospital, Institution or y�-'
j City ow or Village)nd Lain 14 . s� Street Address 113 John .t. K St ul
a Manner of Death r4 Natural Cause ElAccident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
k! Circumstances Investigation
tu Medical Certifier Name Title
Ch r►smkt ,- Jath PA-
Addr ss
) ndt o.41 La kk M/
Death Certificate Filed ,^-' DistrictNumber Register Number
City, To or Village ) ! l&r I a k1L.._ n 5 3 7
❑Burial Date metery r Cre atory
❑Entombment '-a d 2()( / Pi ly. v) ,re tal vi y
Address AY
Cremation 6 I�U,R-
Date Place Removed
Z 1-1
Removal and/or Held
and/or Address
i= Hold
CO
0 Date Point of
N ❑Transportation Shipment
Q by Common Destination
Aili Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to tt II _ Registration Number
Name of Funeral Home NA i t lL „`tp, l l _ en n g q
Address
(t357 strut( oit 1 )1614a/A Lii-Kki Niy iisto-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tt
i
CL
"' Permission is her y gr ted to dispose of the human remains described above as indicated.
Ni Date Issued O Registrar of Vital Statistics -',c( .,6_1, .w Q 4,,( e
, f�?� r / r
)
District Number dU�/� Place �J[7L� �,v
" ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l
lit Date of Disposition 9-I-1 ar Place of Disposition A9,„,a,,� Lrim4i61rw=
2 (address)
to
CC (section) /�/ (lot number) (grave number)
ta Name of Sexton or Person in Char a of Premises ``�� `^ t
Z (p ase print)
iii Signature t Title t` .i'oQ4y)..
(over)
DOH-1555 (02/2004)