Cook, Jared t i/ 701
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
T
f C.d C , COOK Male
Date of Death Age If Veteran of U.S. Armed Forces,
3-i t o- 20(5 ) 7 War or Dates tt o
:j-r Place of Death Hospital, Institution or
W City(1ow or Village -kaki Street Address Ho r r a 5 Rej,
Manner of Death❑Natural C use ElAccident ❑Homicide izi Suicide El Undetermined ri Pending
to Circumstances Investigation
w Medical Certifier Name Title
a IMtc..trladi S 1edtc�.1
Address 1 k , r 1 C ex �' �XQ m i ne r-
ti/a--l- -r-1 rc, / /
Death Certificate Filed District Number Register Number
City, w r Village-I-�(, /P,j
❑Burial Date I eterx 9r Crematory
❑Entombment 03- 1 -7 - 20 15 '1''►Yam.. Vie ) C 1 YY ry
Address
[Cremation Qu&nsb(4
Date Pla y
Removed
Z ri Removal and/or Held
and/or
� Address
Hold
CO
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
« Name of Funeral Home 1-ur -FunefO J 7 / -vy1: Inc. ()Da/ J
Address CAt,l-ral 5t a Lu ze.-nt Aylz ei-6,
02 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'„' Address
it
Iti
!" Permission is hereby granted to dispose of the human re ains described above as indica d.
Mii Date Issued 3 /9-2d/s- Registrar of Vital Statistics j , 4 ��_n. -61
(signature)
gil District Number 9/5:5:3 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILI Date of Disposition 3-,c( -1 S Place of Disposition R n/ J e 1/4,,, (re w,a kr t V vv)
2 (address)
IEEE
Er (section l) (lot number) (grave number)
ti Name of Sexton or Person in Charge of Premises <<`►v+es y 3t`u nelie
J� // (please print)
14 4
Signature lv,.3 � Title Cr,,,,w�c s A.,‘-I-
(over)
DOH-1555 (02/2004)