James, Bruce i.
/I 2.,3 c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First addle Mast Sex
ci3w
• Date of Death Age If Veteran of U.S. Armed Forces,
/� d ij— 67.3 War or Dates
h. Place of Death / Hospital, Institution or ,�
W City,Town or Village Cdrl�5�� BLS Street Address tX 4S / .�, L
Lp Manner of Death(Natural Cause Accident 0 Homicide Suicide Undetermined ri❑Pending
'mil Circumstances Investigation
W Medical Certifier Name Title ./
46
Address
:/, JP6 . < LC Air je,1ora
Death Certificate Filed District Number !! Re ter umber
City,Town or Village Q / O li p
❑Burial Date 3/a / if Ce tery or Crematory
• ❑Entombment
C�,/ `� ",et0-0,5� G"f/7.ir"6 Riedti
�y
Address
&Cremation � ,g ,� � .sS 3 4�2 T �
Date Place Removed
Z Removal and/or Held
0❑and/or Address
it Hold
O Date Point of
CL N Transportation Shipment
G by Common Destination
. s
Carrier
El Disinterment Date Cemetery Address
• Q Reinterment Date Cemetery Address
A. Permit Issued to J1 Registration Number
I Name of Funeral Home 7(7 it d?=� �/Y' l 9 a?�
Address
6 w ,f,F.6A.1 6c< ,�- t s7 /d /
• Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above4s indicated.
PA
Date Issued 3 1 3 c? 1 )5 Registrar of Vital Statistics U�c 'i✓J
(signature)
• District Number
g 60 , Place (ems R, lls , aly
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
14
LUDate of Disposition 3I3e�jts Place of Disposition ,O`.; 6�.,,tEo—
W (address)
U)
CC (section) (lot numbs (grave number)
pName of Sexton or Person in Charge of Premises .w+xi
Z ( tease print)
W Signature -Z` Title (jlE"'iffqk
(over)
DOH-1555(02/2004)