Macy, Jack NEW YORK STATE DEPARTMENT OF HEALT j Z`�
Vital Records Section Burial - Transit Permit
`11 Name First, Middle Last A aC 1 Sex H
J C I-' y
ii Date of Death g I 1 I2(�1� Age 2. If Veteran Do to S. Armed Forces, 1 q y 3^ 1(4,4
Place of Death f bspstal nstutio r
.:. Crciw crrkoiftage ClfcaiW, 1 I s> $ss �ayrle F}mouseof ape_
Manner of Deat Natural Cause �]Accident Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
` Pau/
ri is _i_knc"f,Ph�s)uc�n
Address ----
a.s<. ,--ro - Cent i Et L rr S Fakt s ) I
Death Certificate Filed ' District Number ��� I Register Number
>:. Li( 1111.._ j 33
�.;� - • own ._ :: -
Date s t 131 20(,i f remato p ` f
❑Burial I ` i V
i Address
Cremation j C�
( -r ► CL.) C uAILn-A1x. , 0-1 (2'8o'-i
Date Place Removed
O❑and/or Removal and/or Held
i;,, Address
(15 Hold
i
O Date , Puint of
NQ Transportation i Shipment
a by Common ( Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address 1
Permit Issued to !' Registration Number
€ Name of Funeral Home�"�a'1rla rd f�. gaiter F..cnerrz/ Horne__ j CI ) 3L _ _
>' �/Address rr
L T i F,t(C 3f. , (A.LC.n Sb lr y , , EW YD r t ??Cy
Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
Address I
M
• Permission is hereby granted to dispose of the human remains described above as indicated.
'` : Date Issued s/13 )ab!L1 Registrar of Vital Statistics I. . c
€>: et,nature) ��
's <, District Number 5 1 /p Place T c¢n p f & mil l I\2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i- '
�
WDate of Disposition `b I l H I'M Place of Disposition C 4.--4f» --
2 (address)
LU
CC (section) ( t.numbe (grave number)
CName of Sexton or Person in Charge of Premises ►r,A
g J, 4--- (please print)
Signature Title CDE Ore,0
(over)
DOH-1555 (9/98)