Boller, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
igi Nani.e. First Middle Last Sex
ill a Me. L 11et-- pa k_
igi Date of Death Age If Veteran of U.S. Armed Forces,
- (—Z.o j+ 63 War or Dates no
1. Place of Death / Hospital, Institution r/ r^//�
City, Town or Village( 'kI) I.l 5 j5 Street Address &((AS �/Li th)
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ilk; Manner of Death 670 Natural Cause laAccident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
tit Circumstances Investigation
W Medical CertifierA IX le Title
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(Cp th Certificate Filed ) Dis ict Number Register Number
ity Town or Village c 5 a Lit n1001 2-7 6
❑Burial Date
/-� tt `� metery,o Cremat y /
['Entombment (fir I I 1 Vie, (! afD /
mi Address
ni Cremation '
Date Place Removed
Z Removal and/or Held
9❑and/or Address
H Hold
to
O Date Point of
tL Transportation Shipment •
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iii :qi Permit Issued to �-'' I Registration Number
Name of Funeral Home �'`f 3C'-r t.fQ Wiz. 1--{ _ I {id 00a1
Address
'0` eirqt rc h t uze rn e_ A '/ 26
Hi Name of Funeral Firm Making Disposition or to Whom `
Remains are Shipped, If Other than Above '
2 Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/ ( / /5 Registrar of Vital Statistics V.) CA..' , •
'i a, (signature)
iii District Number rj I Place 6 S 1\\5 i tiL'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,',
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al Date of Disposition 4I 3 1(�' Place of Disposition 1 6.40ti.
2 (address)
CC (section) Alot numb r) (grave number)"
pName of Sexton or Person in Charge of Premises AIL t M 'i .
z (pl se print) •
iti Signature �°"n Title at 014Pit
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DOH-1555 (02/2004)