Cooney, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
_ .
Name First )ct
�} ddle Last Sgoc
PVC bAP., cV
Date of Death i Age If Veteran of U.S. rmed Forces,
'1 -I?.- Dpi - 1 War or Dates - 9D
�- Pla th /� Hospital, Institutior}ior ��
W City own o `Village l .1 (2y1 (Aii, Street Address -th,L S
3 Ma eath Natural Cause ❑ snent ❑Homicide ❑Suicide ❑Undetermined El Pending
t1J Circumstances Investigation
Ili• Medical Certifier Name Title
O 4 A_r>v,e‘ DC-01 0 ill\-
Address
c-i -
Deat ate Filed istrict N _ber Register Number
Cit , Town o illage C' s s `1 ) D-19-
❑Banal Date -i -�‘ Gen etterxF Creme
['Entombment Addre
Ze_c
t e t.e.�.� (0-.
y1 Cremation q,...,.....„4),,..„.75,--Date )Place Removed
❑Removal and/or Held
and/or Address
E- Hold
Cl)
O Date Point of
05❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to , Registratiprumber
r itName of Funeral Home rAct._ v,..�r ),--\cyb,_, ,, c�
Address 1 44'ie
V T
111111 Name of Funeral Firm Making Disposition or tooWhom I
Remains are Shipped, If Other than Above
• Address
cr
9 Permission is hereby granted to dispose of the human ° -m-."ns de,ri - 'ell"- at.,A
Date Issued -I fs Registrar of Vital Statistics A,
( gnature)
District Number -j iA-1 Place D(A)-N\. -z to,,�� -t-i-v.
' I certify that the remains of the decedent identified above were t posed of in accordance - is p- it o on:
LU Date of Disposition 7f itcps- Place of Disposition . ru ua..i Lrt dt,
2 (address)
Ui
Cl)
CC (section) , (lot number) (grave number)
AI!
Name of Sexton or Person in Ch rge of Premises A t, ,se,se`""��
(pl as—
e print)
• Signature Z
} Title fIlk, `(
(over)
DOH-1555 (02/2004)