Johnson, Henry NEW YORK STATE DEPARTMENT OF HEALTH
—Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
n e,A.r (.D . J ok&s J.� Ai tiL.c___
Date of Death Age ' If Veteran of U.S. Armed Forces,
1 /3/ o r S_ 1 5--- War or Dates L.. ' r • .
)__, Plac- • Death Hospital. Institution or ZC /D City own .r Village (...„‘"fra/---- b I Street Address o
w Man : : Death - Natural Cause 0 Accident Homicide Suicide Undetermined Pending
aCircumstances Investigation
W Medical Certifier Name Title
a NkciA,l&4,- KvA-to eiN0
Address f{ �q
Death -• ficate Filed District �umb ' Register Number
City/town o Village < v r. -i _ `t 5_S- •
Date Cemetery r Crematory
EBurial /3f a0( 5-" ;ii� u.e_.,.r 6c�ti-{mot
Address
Y Cremation /
Date Place Removed
Z " Removal and/or Held •
- J and/or Address
- Hold
O Date Point of
0 `Transportation Shipment
a by Common Destination
Carrier
^'Disinterment Date Cemetery Address
_— Reinterment Date Cemetery Address
'
Permit Issued to ce— Registration Number
i
Name of Funeral Ho�GAry
.5 ,.r._ I„.Acr4 L N'.n4' / ^-C-- Dvlr'rV
Address _
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above I
Address
i
Permission : 2x
heeb granted to dispose of the human r a ns scribed ov s ' icated.
Date Issued /ao/ 5 Registrar of Vital Statistics
• a re)
District Number `�`5 5 3 -Place Cam :r ti1 ( =i--) /or vl
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tz Date of Disposition Z/3]Ir Place of Disposition{ — Cry
2 (address) -
w
V
CC (section) OF/nu ber . (grave number)
0 Name of Sexton or Per on in Ch ge of Premises twt9'
(please print)
Z W Signature t�rP,Title �f
DOH-1555 (10/89) p. 1 of 2 VS-61