Kennedy, Jesse NEW YORK STATE DEPARTMENT OF HEALTH` • i 3't
Vital Records Section Burial - Transit Permit
':`= Name First Mt Ile Last I Sex
( II _S E-SS ���ti iJ>J E. l 11 ,
aiii Date of Death _ Age I If Veteran of U.S. Armed Forces,
04/a , /an i S �� j War or Dates le% ( 0- Cp.4-
iiPlace of Death I Hospital, Institution or
rA City, Town or Village FO rt- t r N Street Address S 1 in't Lh`V A ti L t
3 Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
U Circumstances Investigation
Medical Certifier Name Title
01- 3osE.9 µ C. MINttiDv
IIIIIIIII Address
IIIIIIIII 9.0 e"Iv 2Z-ALt S7 (D Lt.NS -FALL-5 Lt t ego 1
Death C ificate Filed District Neer 1 Regist r Number
City, own .r Village L7c � i J
' Date I Cemetery or Crematory
:I I 0 Burial Lt" t .s / a-015 Pi (.3 U t L L,...) C z. c -0,--co _`i
Address /� t�
I: MCremation Q-�A '��R Z7 QU�E.(N St3U� K`� 1 i DAc) I
1 Date i Place Removed
0❑Removal I and/or Held
•— and/or Address
0
Hold
0 Date I Point of
ftni C Transportation ( Shipment
by Common Destination
Carrier
0
Disinterment Date Cemetery Address
II
Reinterment 1 Date Cemetery Address
1
Permit Issued to / L Registration Number
Name of Funeral Home 53PK t--;� vt4ar. ;E,- 01/3Q
` <+ Address
IIIIIIIIII) !{ r r✓) 3 Ifr- T , o ;t -r.sS 6 U 1' y /2. t` t
Name of Funeral F Making Disposition or to Whom i 1 `
Remains are Shipped, If Other than Above r�
P
Address
II I
:Ckc
Permission is hereby granted to dispose of the human remains d cribed above as j •ted.
I Date Issued 7—07 e-J Registrar of Vital Statistics 1 e_e- 4:411.:' ' 4- -
'' / (signature)
<I District Number Place 7Z ra -7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f=
6 Date of Disposition 4/NilIS— Place of Disposition etil. f:-� e---
2 (address)
iLl
(section) Alot number) (grave number)
LIJ ICi Name of Sexton or Person in Charge of Premises • . .. >
z (please print)
t Signature LPL- 4 . Title i K4ihtiktrt.
(over)
DOH-1555 (9/98)
i cet w y 1,1W me .G.,,..........— _.
Z Date of Disposition 5�bli Place of Disposition (add )
(section) (toti,umber) (grave number)
ti
Name of Sexton or Person in Char a of Premises_CI (please print)
g Z Title C4
tit Signature_
(over)
DOH-1555 (9/98)