Mack, William ' 11 CI(6
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle`,) fNe)ast ' Sex
Date of Death Age _ If Veteran of U.S Armed Forces,
0 )( 4 S (-)_.c__)l LA_ ; 5 (2, j War or Dates
Place of Death i Hospital, Institution or \ i
City, Town or Village Of Islandia { Street Address `�`1 L��k t o<< > 3 �r �L
Manner of Death Natural Cause E Accident C Homicide ',Suicide C Undetermined C Pending
Circumstances Investigation
Medical Certifier Name Title
in
Address
1 ,,'\,)
Death Certificate Filed ' District Number I Register Number
City, Town or Village of Islandia 5121 1
Date Cemetery or Crematory
❑Burial 1 ) / o )`-1 i � nL 1e �✓ Cct,ri'N( .(-) C'}
Address
Cremation; ` l'• \/' .
. Date f Place Removed
fl r' Removal and/or Held
I-
- and/or Address
) Hold -
Q ; Date ; Point of
gsiE Transportation ! Shipment
5 by Common ' Destination
Carrier
E Disinterment
1 Date --� ' Cemetery Address —
l i Reinterment Date Cemetery Address
Permit Issued to r Registration Number
Name of Funeral Home 'i e.a)c,n 'a)Q,�.0 y (�-\-�.,c-c-�,e G1 I )-' . 1 T? ,`j 3 _�
Address _
( yrA2c. I, `J��c:c,G' E 'V;e�.);�a�r /
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address -- ----- ----.----________ __--
Ul
P.
Permission is hereby granted to dispose of the huma described abo • icated.
Date Issued I. /1' /At Registrar of Vital Statistics
sig ature)
District Number 5121 Place IS1 andi a, New York 11749
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t-
5 Date of Disposition ?- 27—E4 Place of Disposition 4—• T10--
2 (address)
tU
tl
CC (section) lot numI er) (grave number)
G Name of Sexton or Person - Charge of Premises d
' eaNifi
Z L (please print)
Signature Title Crr nhoK.
(over)
DOH-1555 (9/98)