Daley, John NEW YORK STATE DEPARTMENT OF HEALTH # Jc
Vital Records Section Burial - Transit Permit
Name First....,--
Date Middle /1 A Last , etC���
J b Nov �.,J � 7
of Death Age If Veteran of U.S.Am q ii Forces,
f//1/ is- 7 ' War or Dates
i- Place of Death �1 Hospital, Institution or
W City, own_ Village UCGJ. �aLt. -'/ Street Address S?�0-0�S 611 U.RCS/�S 6-
p Mari each Natural Cause A dent Homicide Suicide �Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
io TES i,y,A) S c-De.O ;F , E9,
Address n ,)
/ S.S .e 1 t 9s`! 4) .._ Q2,Lot c.1-.$ A/ -426fi''`/
Death Certificate Filed ���� �� District Number egist*umber
' City r Village Leaf -'S B&t 7 5 US 1 i 1 L
❑Burial DateCemetery or Crematory
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❑ jEntombment Address n ^
Cremation �/ 1 60 4 -. 7 , ed. ..21/'s & / y ay 9
Date Place Removed
gi-,Removal and/or Held
and/or Address
Hold
0 Date Point of
0 Transportation Shipment
0 by Common Destination •
Carrier
1:3Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home AAkb Fr 1::.— (e 19 6
Address
/'3 e()/clic'ie 6,0(z,A:s UGC S 7 /=.?dt
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
3 Address
W'
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 l- 3- l 5 Registrar of Vital Statistics '"2 • �a� �c e �
(signature)
District Number 5�s 1 Place Q v C.cnS b/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition 11 /N I is Place of Disposition 4? il,t., t�r/ �fiot ivy
Ili (address)
Cl)
cc (section) A (lot number) (grave number)
pName of Sexton or Person in Charge f Premises L hr sE r lr+++��
Z /� �ealease print)
W Signature yr Title (I7F-Aril
(over)
DOH-1555(02/2004)
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