Lane, James NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name JCu &S
irst A Middle Last Sex
ff f I)e _ Lao c m'k--
Date of Death A ! If Veteran of U.S. Armed Forces,
I 1 1 O 12.0 i j 2_ War or Dates /9 ro 3- )' cb 7.
I Place of Death Hospital, Institution or
City, T�ir or Village t3 Je_ .YYA Street Address _
Manner of Death El Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined �Pending
tf Circumstances Investigation
in Medical Certifier Name Title
G? plvzn r zes r ris�,t Pi - D D .
Address
3(-4- 3 . inc,n,',16 (Rl Jct. sulk 220, 4I - i i t I z20 e-
::,,,,:: Death ificate Filed CJ District Number Register Npmb r
City, ow or Village , ,)-eh e r\t‘ /
❑Burial Date Cemetery or Crematory
1 'Ol1z v/ 3 -PiA.e V,QriJ Ciere311 4-1-1 `I
Entombment Address
(Cremation ZI & j„¢r- kcA t„t te-clt5 b , pi J28"06(
Date Place Removed
❑Removal and/or Held
and/or
Address�;;
In
Hold
0 Date Point of
I Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M e7 AA /ni f i-1. 7/ ) -
< Addes
G0 Kna t:✓) S - SvLcy--4 e/.ens -Pc,,k,st kv l zc _y.p :
<> Name of Funeral Firm Making Disposition or to Whom
-- Remains are Shipped, If Other than Above
• Address
Ili
Lt Permission is hereby granted to dispose of the human r } described above s indicated.
Date Issued /17:10-/)Registrar of Vital Statistic , jj'',-__
7 (signature) 6/ i� 172
il District Number A----/ Place , `� � L,_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ill• Date of Disposition rZ(2i6 Place of Disposition egvik. Crtn-form
2 (address)
LEE
tn.
re (section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises An, _c)►*t1[.-
(ple se print)
Signature �` ��-" '� Title Elliftlitik
(over)
DOH-1555 (02/2004)