Monroe, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH tn/
Vital Records Section 4 Burial - Transit Permit
Name First tz Middle L st Sex
Date of Death • l A e If Veteran of U.S. Armed F rces,
to/ V//1- P Z War or Dates AR-
f- Place f eath Hospital, Institution or
W Cit , Towir or Village C_ ��L�. reet Addre ) ,? 't Y Q(.//(S?-e�.80)GL W120
W Manner of Death Natural Cause ❑Accident Homicide 0 Suicide ❑ Undetermined Pending
Circumstances Investigation
Ill Medical Certifier Name -��- 1 ` (\\�� pTitle /t�, {y�\
0 V o/V'N S:-a-li 7 --A it?t? viA-el y V
Address Q/)
/a 2 V Si , CLe',)s F2uS A
Dea t icate Filed District Number / Register Number
Cit , Tow r Village hu5 C-vt_ 06,6, p
OBurial Date tor
eo /.2-&-//.1" Cemetery rema /'i.Jt! V/f1-J❑Entombment
Address
2/Cremation LA v`9-/.0�, G IS,NS 7Ai
Date Place Removed
Removal and/or Held
i
... and/or Address
H Hold
0 Date I Point of
DS Q Transportation I Shipment
6: by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 73 pie_,, 5 < . ,/,y 0/ /3 D
Address
// ( 017-197&--17-67- ''--- Ca u 6fy-is a 0, ,/, (y ( e-FO
Name of Funeral Firm Makingruisposition or to Whom /
1.4: Remains are Shipped, If Other than Above
2 Address
CC
t
Permission is hereby granted to dispose of the human m 'ns def;cr' ed ove as indicated.
Date Issued 6.7/o&5/M Registrar of Vital Statistics f1_, J • „Ptak
(signa ure)
District Number &./� Place `J. C�4 ,,,teir.
1 I certify that the remains of the decedent identified abo a were disposed of in accordance with this permit on:
I
lW Date of Disposition 0?6--(5 Place of Disposition2apu;e9,4 j Cr eWl titor t'V W1
141
(address)
CO
Ce (section (lot number) (grave number)
fa Name of Sexton or Person in Charg,: of Premises I imp fly N/W It
W �4 1/ (please print)).)
Signature Title CiC c �c i i s '
(over)
DOH-1555 (02/2004)