Jones, Gerald NEW YORK STATE DEPARTMENT OF HEALTH N v'-
Vital Records Section - a Burial - Transit Permit
Name First Middle .. -Last Sex
iAA
( i--z- -b J 6 4)*-rb
i . Date of Death Age p If Veteran of U.S, r d Forces,
05 -0 Z-`Z-O i'S- "1 -I War or Dates 0 t-N
P - of Death Hospital, Institution or-
own or Village ./ Street Address C.p7J l 1
ttit
inner of Death Q Natural Cause E Accident Homicide E Suicide Undetermined C Pending
W. Circumstances Investigation
Medical Certifier Name Title
Ail(*) �t.Dot , �
Mi Addre
3 , ,-f Ate, ; IVY' ��z
Death Certificate Filed `l District Number Register Number
giiii it, own or Village r
`<'< ❑BUrial Date C etery
rematory
' OS-® l� ` {1�GV i tom+ Dt,v❑E mbment
Addres ( p
lillili Cremation 1� . v \\ :,,s- . ' J, >�k/ P-o OL[
Date -'lace? Loved
Removal and/or Held
and/or Address
W Hold
#!
C Date Point of
Transportation Shipment
is by Common Destination
Carrier
Q Disinterment Date Cemetery Address
II0 Reinterment Date Cemetery Address
. Permit Issued to Registration Number `
Name of Funeral Home M .6- WIij+--tA4 t- Ft/pep/et, I--/vime 0 io-77
Address
iiiiiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
LAI
` Permission is hereby granted to dispose of the human remains described above� - as indicated.
in< Date Issued �03 7,0 N Registrar of Vital Statistics i ' . ,t%'�v W 1. i i-t/ it,
(signature)
District Number Place ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition S/blic Place of Disposition Zt( ek.
f (address)
0
M (section) (lot number) (grave number)
Name of Sexton or Person in harge of remises fi•I ,-
"14 / (pl ase print)
Signature ljs Title fPEA j ,� (over)
. DOH-1555 (02/2004)