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Jaffe, Joseph
1 NEW YORK STATE DEPARTMENT OF HEALTH f It t tibf Vital Records Section Burial - Transit Permit Name FirstMiddle -- L t Sex AgeIf Veteran of U.S. Arrh d Date of Death So Se� / Forces, 7/3// ;�o r1__ (0.5 War or Dates Place of Deat Hospital, Institution or Z City. Town r Villag _.nP•q--E1..- Street Address 'a,),It .114 A lc S W Manner of Dear Natural Cause 0 Accident 0 Homicide 0 Suicide � Und ermined C Pending Circumstances Investigation Medical Certifier Nam ` �� Title CI cl_ (/� &n Address oAr„. la,,, S- -, _ 6LG - --t--.z',t'� Ai 4y LZgo( ) Death Certificate Filed -- District Number r Register Nu er City, Town or Village (...0``,1' et S . 1 31 _ Date Cemetery or Crematory __Burial S/ f i a°O.--- ;le_v;c (.,-, 6c-,,..,-1-0 t Address /' Cremation C;�e_r":,,,.5 L - JJc (C,rv( Date Place Removed Z —Removal and/or Held O —and/or Address 0 Hold O Date ' Point of Transportation Shipment E by Common Destination Carrier • .--•Disinterment Date Cemetery Address —Reinterment Date Cemetery Address Permit Issued to _ Registration Number Name of Funeral HomOr--e-vt S -D� 1 t-,,•.�e.l 1N>w, 7- , ©0 Address 7 SLI crµ,G,. Ave i Cam,. i, ,. 1 A s),2- Name of Funeral Firm Making Disposition or to Whom r"'"' Remains are Shipped, If Other than Above gAddress Permission is hereby granted to dispose of the human r• • - • :scribed ov s ' icated. Date Issued 7/31 h2-- Registrar of Vital Statistics I ••a ire) District Number 11 S 41_1____ Place ( ----a 0. t - TJ G%.a (,--.0 r I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- ;� Date of Disposition $-l-tt Place of Disposition '1'/w(uuiv C r*6.411r _• (address) u.! CC (section) 4 (lot number) (grave number) Name of Sexton or Person in Charge of Premises / rra L-' S 6' z (please print) I W Signature irii _ / Title e! ktiw� DOH-1555 (10/89) p. 1 of 2 VS-61