Waite, Jason 7l0
NEW YORK STATE DEPARTMENT OF HEALTH ?
Vital Records Section Burial - Transit Permit
Name F st Middle Last Sex
Date of Death / L Age If Veteran of U.S. Ar ed Forces,
`7 ',3 )`T 024, War or Dates p
j- Place of Death � ]�� Hospital, Institute or
W Ci „ Town or VillageCj/ 13 Ya V Street Addressc)e�5 -lQl(s /jai
W Manner of Death E Natural Cause Accident n Homicide n Suicide UndetermineI Pending
1� Circumstances Investigation
tu Medical Certifi m itle
CI �-t.v`1 1 tna►� M,v.
Addees t,(,1"� /v
Death Certificate filed J / District Number Register Number
Ci Town or Village Q I ens l iS No0/ , ‘/.
El Burial Date C etery pr Crem ttorry,,� ,,
❑Entombment 7-,z9- 014 ' ' rut_ LW "" ai-0124
Address,-..
Qkw r4Vm ja.S 0 C�
ZDate lace Reojied
2 ❑Removal and/or Held
and/or Address
IZ:: Hold
tel
0 Date Point of
NQ Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to 1AJ( 1 �� � Registration Number
Name of Funeral Home1r- ,� 1 ,Q 41U errant el Inc QQc 11
Address DI-- Church ct La-14.. 1--111---P-mk, Aq
ilgikp
Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
'; Address
ltf
rt. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 112 5 1 (cU Registrar of Vital Statistics C,A 0 ` Q (A)
1 (signature)
District Number 5'6 0 I' Place 6 (n S 'T'`S, Of/
v
I certify that the remains of the decedent identified above were disposed of in ac ordance with this permit on:
W Date of Disposition 109-4 Place of Disposition P/VL V, /47
2 (address)
111
In
CC (section) \..5 " 011.tnu er)d (grave number)
ZName of Sexton or ers i r e of Premises
g_ l ea a p t)Signature t� Title 0,660740, ,e
(over)
DOH-1555 (02/2004)