Loading...
Harren, Kevin NEW YORK STATE DEPARTMENT OF HEALTH �. '+ 11 L ill Vital Records Section Burial - Transit Permit Name First Middle Last. Sex /e v�.` �/9ae/ZL- - fl Date of Death ``/a/���� Age j�- If Veteran of U.S. Armed Forces, War or Dates Place of Death i„av / Hospital, Institution or / / f/ /.765 i / City own or Village Street Address �r/-Gt-wo 1 P1 6 Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W0 Circumstances Investigation ul Medical Certifier Name Title 44 SG0n / 43 I A 0- Address /w /4A-� 5 j /- /4A /t)Y th Certificate Filed j // District Number Register Number City,ty�` wn or Village / i �`�a! :j 60/ 6T ', Burial Date `7A-V20/2- Cemetery or -- /4 o 6 /f !A-t -::::.i❑Entombment Address`Cremation 0U.e 4104X /vY /a 'Dr Date Place Removed Z❑Removal and/or Held 14 and/or Address — Hold to 0 Date Point of It il Transportation Shipment a by Common Destination iiig Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to /� `` �" ��// Registration Number Name of Funeral Home /�41 d. '.41�-� L4 da _ ©/30 Address iiiil Name of Funeral Firm Making Disposition or to Whom } Remains are Shipped, If Other than Above a Address Iu Permission is hereby granted to dispose of the human remains d cribee ab ve i icated. Date Issued 1,23 /Z- Registrar of Vital Statistics A ` �' (signature) District Number SO/ Place A tix I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 111 Date of Disposition it/Z1 il Z Place of Disposition —RIL Cr,t,,, );t4". (address) III to ix (section) A (lot number) (grave number) 0 Name of Sexton or Person in Char a of Premises �� (please print) 1E Signature " d- " — Title riiesupoi, (over) DOH-1555 (02/2004)