Levack Jr, Harold {_ 4 L3(
NEW YORK STATE DEPARTMENT OF HEALTH. 1
Vital Records Section - Burial - Transit Permit
%i Name First Middle Last I Sex
I-taro ► cl ,_..,Middle
e Le\i ac K. Sc . M
Date of Death Age Veteran of U.S. Armed Forces,
10 \� \2_OH 1 War or Dates I CI CS O-- iG C_P`I
.....: ;e of Death Hospita _
CI Glens VG.\ \S Clens Fa-i1S
Manner of Deat Natural Cause �Accident n Homicide n Suicide
Name Title Undetermined Pending
Circumstances Investigation
Medical Certifier
41 Dr-. K amo- l t`ICJ
_g Address
, too Pc‹-At . N (. \-e `-5 F�\\5 lam\ tag o f
:r Death Certificate Filed District Number ; Register Number
City, Town or Village 5 Ld I j Li 6 b
Date i Cemetery or Crematory
❑Burial 1.0 h aO\'-}— 1 P,ele_U`,ew �Ycr..<Ao��
Address/ H
®Cremation Uvecs,‘s L1 1 a21:D Li
Date i Place Removed
2 El O Removal ; and/or Heid
iL.2 and/or Address — — --
t� Hold
Cj Date ; Point of
NQ Transportation i Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
1:1 El Reinterment
Date Cemetery Address
Permit Issued to ; Registration Number
< ��'
� Name of Funeral Home �`-��a�� �jC2.kf� �cne�cc-�
/*me
I t 3C�
Address
;;.. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
al Address _- - ------ - --- -
Maps
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued !0 /'J I t y Registrar of Vital Statistics W cam- W- - U
€? (signature)
<�( District Number 560 / Place 6 S �\\ S j N y
':a:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
5 Date of Disposition to/' fri Place of Disposition �Rtiw., C j1:;...
2 (address)
ill
tR
it (section) (lot nurpber) (grave number)
Name of Sexton or Person in Charge of Premises ____ L+1`4Cli1•
Z (please print)
Signature t11 . 2Title C4 1? L
(over)
DOH-1555 (9/98)