Cody, Jon NEW YORK STATE DEPARTMENT OF HEALTH ("
Vital Records Section al.
• 0• Burial - Transit Permit
t=>`" Name First z Middle S
et...„,
;<. Date of Death ) ( Age ! If Veteran of U.S. Armed FFrces,
7 Z2. /�' '7S— War or Dates V6r1 1JA/K•Jvw..tJ 1- 611vz-.S
.``•-� Plac- • Death • Hos ital Institution or r /
* Ci , Town Village �)f ,y/t,J Street Address (,)tr ,iy Crwik_ 16'
,.; Manner of Deat Natural Cause f Accident n Homicide n Suicide ri Und4termined ri Pending
jA
Circumstances Investigation
it Medical Certifier Name Title
ro- rE H, )9,3 /I
Address
ta
`` Death Certificate Filed
`" District Number 1 Register Number
ai Ci Tow •r Village 7 ,y1 oy ,J i s-(S" c I
Date 1 Cemetery CremaCory
Burial ! 7Jz9 AS-- --it-A) 1),AddressI^l E>� ��^-)
,... Cremation....
i 1 loll ; j J . -'S Q i✓�Y� Ai
2❑Removal Date 1 Place Removed �'
and/or and/or Nelct
�:: Address — ---
Hold
Date ' P:;int of ---
N❑Transportation
Shipment
Q by Common Destination
Carrier
�j Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home faker �C c ieccL/ name_
j Registration Number
�» Address ,I On 30
ll LC-IL y.11e vf. , ( (ALc,,c)SbLLrci i AJ w YOCX- l agoy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
6- Address
I
.g.
Permission is h reby ranted to dispose of the human re ins described o a in• cated.
iiig Date Issued 7/Z`3/l.l--- Registrar of Vital Statistics 11' i
( ignature)
'<' District Number -VIPS / Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
6 Date of Disposition7"'34 -IS Place of Disposition I r49 1/0,ew Crzji.,cior •"✓,••
(address)
cc
Z Name of of Sexton
f r Person in Charge of Premises ( ect. n (lot number)
�--s (grave number)
t:: Signature Lt#,z'7' 4,,,j (please print)Title__Crek, fhp�—Qrr4
(over)
DOH-1555 (9/98)