Weeks, Jean NEW YORK STATE DEPARTMENT OF HEALTH t ' # 0,3 b
Vital Records Section Burial - Transit Permit
Name Middle Last tx
,EQ.
co
Date of Reath` A If Veteran of U.S. Armed Forces,
a [Ls ! i _ War or Dates
}- Place th Hospital, Institution or
Z Cit , Town or illage{ [.tom Street Address
111
Man ei u eath 'i Natural Cause ❑AAcc. e t ❑Homicide ElSuicide ❑Undetermined ri❑Pending
111 Circumstances Investigation
W Medical Certifier Names/ / �j Title
0 4////��r'f? &t- , 'fl/
.Address
/y 111./Y2aV- &) pie a,�.e e i�s d , �L / �0
Death ificate Filed f Dis ict Number Re ier Number
9
City, ownnoo Village �( LJG �fl I L-)
❑Burial Date Cemetery or Crematory
['Entombment Address
-9r`"/2 /d✓7 et, (/%P'1") ./e ✓
Address Q >
d/
:Cremation �jtc� �,�CP_-,i % , a e 21�Sb(A Ai//..F4
Date Place Remove
❑Removal and/or Held
9and/or Address
H Hold
O Date Point of
EL` Transportation Shipment
Di
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home e, ,� ����e..,� //30
Address
n Ze>1.7 ' ye- v rt / 6&'eevsb'l1 ,/ft//21)
Name of Funeral Firm Making Disposition or to Whom ,
Remains are Shipped, If Other than Above
;; Address
2
t:
CL
Permission is hereby ranted to dispose of the human remains described above s indicated.
Date Issued 1 c:D C lc 141egistrar of Vital Statistics C; r
11..,(—.-,,
(signature)
RB District Number gc Place ) 0 0.„...., C� a) „,,,,i,
I certify that the remains of the decedent identified above were disposed of in accord• ce with his permit on:
I>`
2
ILI Date of Disposition i 2-ft,-%1_ Place of Disposition ttv C !�
a (address)
Ili
W
C (section) i , (lot number) (grave number)
Name of Sexton or Person in Charge f Premises / c tt4L_ Q.v4`-
2I(please print)
Signature /PL
Title CVAM1tr ,
(over)
DOH-1555 (02/2004)