McCauley, John NEW YORK STATE DEPARTMENT OF HEALTH 1 f 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John William McCauley Male
Date of Death Age If Veteran of U.S. Armed Forces,
17077014 91 War or Dates 1943-1945
l Place of Death Hospital, Institution or
Cityiii , pillage Albany Street Address 113 Holland Ave.
Q Manner of Death®Natural Cause Accident 0 Homicide 0Suicide �Undetermined Pending
l Circumstances Investigation
Ili Medical Certifier Name Title
Q. M.D.
Address
- 113 Holland: Ave.,
s Death Certificate Filed District Number Register Number
> > City, ICMCWOOttne Albany 198 189
OBurial Date ^^ + 1 C)\ \I Cemete or Crematory
❑Entombment `dam / p;,:e_ ,w C rt. a\-o.-
Address
®cremation ��"lCb"`- ( '� 7�.at ti_L'3 v„
Date I F'lace Removed ' -
Removal ' I and/or Held
... and/or Address
CZ Hold
. s_ --_ __--
Date Point of
Transportation Shipment
ci by Common Destination
iiig Carrier
:: Disinterment Date Cemetery Address
iip
Reinterment Date Cemetery Address
Permit Issued to m ;� t� Registration Number
Name of Funeral Home Mq:1�fat).._ V. RAW 16Nt RAL i4c t- C AC3 0
Address
't\ LA FAk E -rrc: Sr Gov 6-�►.1 5(3.3 tZti tJ '1 tar` ot4
loi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ui
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 120714_ Registrar of Vital Statistics James Arrington, Manager VSC _ __
(signature)
District Number 198 Place DVAMC Albany, NY 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
iii Date of Disposition I i('ilii Place of Disposition , C. F._.
AAA iw •
2 (address)
tu
ce (section) (lot number) (grave number)
Ct
ci Name of Sexton or Person in Charge of Premises 6 ..bi e.44
�*� (please print)
Signature �� Title Cat fliAtTe-
(over)
DOH-1555 (02/2004)