Bright, Francis NEW YORK STATE DEPARTMENT OF HEAL', + -L 1 LA
Vital Records Section Burial - Transit Permit
Name First Middle ,LLast/— Sex
Date of Death i Age p If Veteran of U.S. Armed Forces,
/p2 -O C�- pGj/S /� War or Dates A o
#- Place of Death Hospital, Institution or
W City, Town or Village l 1 Go'Le r 4. Street Address /a 5- (� Afr ler S
0 Manner of Death EINatural Cause 0 Accident ❑Homicide 0 Suicide ri Undetermined 0 Pending
IU Circumstances Investigation
iii Medical Certifier 0vvgwe Title
0 (f ler -- !Aye !41�
Address / ` �J
(7 `'/r''%/er /6 - 6 'c 04— fr ,� r g fay
Death Certificate Filed District Number �j Register Number
City, Town or Village t i'cc 1..'�(,re, A �J�Sl L1 ��
❑Burial Date Cemeterp or Crematory
❑Entombment 0 0I- aid/5 (t `14e t).Fib rre-•-(N tcL y
Address
:' Cremation L)._ez;5 b �„?, N
Date Plake Removed
Z ri❑Removal and/or Held
and/or Address
file?
Hold
Date Point of
tki❑
Transportation Shipment
23 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ( Registration Number
Name of Funeral Home �c`u)W Ll� �UM;vvgJ �� 06�^�
Address -S4 J-ar,,, 1_, , 6 1,_.)
:„„„„,: Name of Funeral Firm Making Disposition or to Whom/
Remains are Shipped, If Other than Above
Z Address
ix
Permission is hereb granted to dispose of the human remains ibed above a indica
Date Issued Z R \ - Registrar of Vital Statistics ./0C1Y\
(signature)
ei District Number /5'q Place C---- i 2 r
I certifythat the remains of the decedent identified above were dis ose of in accordance with this permit on:
p
k
t:LI Date of Disposition Ilia l it Place of Disposition eV , Ci*^vw' 1t,✓
2 (address)
L
>I
ce (section) .(Jot number) (grave number)
CI Name of Sexton or Person in Charge f Premises XII*.
��'*
Z ( lease print)
W
id Signature Title cif
(over)
DOH-1555 (02/2004)