Reilly Jr, James ittNEW YORK STATE DEPARTMENT OF HEALI H i ���
Vital Records Section Burial - Transit Permit
Name inrs eS L.IJ Middle,'+ L Last Sex I
-mot �,�i I1 f Ma
Date of Death Age If Veteran of U.S. Armed Forces,
- '7">�1 t-+ 71 War or Dates j f 0
1 Place of Death Hospital, Institute r 1 �_�
Town or Village ��S (�f Street Address cD[-ergs 1'Gt f L 17r Q1*/
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined) ❑Pending
ILICircumstances Investigation
Medical Certifier Name Title
r Jen n if-cc artrUo kith
Address
Guee oe.nj Ni< th Certificate e D istric Number Regi�sterNumber
i Town or VillageLlc)W I�s 01 "_ 53
mi
❑Burial Date.07la 1 ao i 4 137rnetevioQe tory►'�.(1�Q i v
❑Entombment Addr �
^ r fj
Cremation ,fl U.CiS Unat!V
Date V 1 Place Removed
,'0 Removal and/or Held
41 and/or Address
.1= Hold
11)
0 Date Point of
tit)Li Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to — Registration Number
>: Name of Funeral Home1:34ftWer I nC, OM ( k
Address l J► w -c s ) LoLick Lu L_e.A, A v/ l 24
Name of Funeral Firm Making Disposition or to Whom
;M- Remains are Shipped, If Other than Above
Address
i
Ain
• Permission is h re granted to dispose of the human remains desc i ed abov as i ' ted.
Date Issued 7 aI .20/ Registrar of Vital Statistics (signature)
District Number I Place 4lijop G Ieri _(Ls
,...,,:,,,,,,„ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la• Date of Disposition 1-23-I9 Place of Disposition ini,U>w (,revitOr
(address)
In
co
Ifs (section) (lot number) C (grave number)
Name of Sexton or Person in Charge of Pre ises r. - SEetetri
2
A (please print)
• Signature Title GPC41,1 d4
. (over)
DOH-1555 (02/2004)