LaRock, John NEW YORK STATE DEPARTMENT OF HEALTH k-icc°
Vital Records Section . : Burial - Transit Permit
Name First Middle \A, Last Sex t n
'i Date of Death I Age I If Veteran of U.S. Armed Forces,
LO`4 1 115 �D War or Dates
. Place . Death 1, 1 Ho .. - titution or
.'': City To, n ir Village i�.t �,�, I 'i eet Addres s% 5t- `hdhcb "L� '�d •
;.. Manner o Deat,a Natural Cause 0 Accident ❑Homicide 0 Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
t Address .20 i` k-u1/4 rrC 5 - 6 UQ.I�.p F—Cx A , m 1 Zs3O 1
Death icate Filed District Number } Register Number
M City Town Village �1(l.C.P6l_lA 0 i S 76 ) 1 <F
mato > (�
<': E Burial Date lQ'23 '2o15 Cemetery re i C . k
Address ���� kJ , �� , A '
Cremation Q o•NJ 6 i A�1 7 2-i�
Date i Place Removed
Removal and/or Reid
and/or i Address
0
old
0 ! Date - -- Point of
51)4 n Transportation { Shipment
a by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date ; Cemetery Address
!> Permit Issued to Registration Number
Name of Funeral Home aft er� Funeral //ome_ t Of ) 30
iliiIii Address
l J LC� a y€ fe . , uaRkensbt t..rcj , /ve w LJork- l yGy
p Name of Funeral Firm Making Disposition or to Whom
-''" Remains are Shipped, If Other than Above
414 Address
a
: Permission is hereby granted to dispose of the human remains described above as indicated.
igiii!-' Date Issued o-13-.)--6/s Registrar of Vital Statistics IA; Cam- �
(si 9 a )
District Number 5 -)6)- Place 7- wn p -( /i',I j.f 4yr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
E Date of Disposition C-?y-f S Place of Disposition `f i ne V e-.) CI er'i4ori um
2 (address)
114
In
O (sectio ) (lot number) (grave number)
C Name of Sexton or Person in Charge of Premises -- (
g (please pri t)
141 Signature Title CI'en.a-1ar . 1454-
(over)
DOH-1555 (9/98)