Coons, Jr. Raymond NEW YORK STATE DEPARTMENT OF HE,^:LT -►-
Vital Records Section „, Burial - Transit Permit
Name First Mid e Last .. - S?
t M DA I (�.2GA 5' -Q r1 . L�
Date of Death Age If Veteran of U.S. Armed Forces,
II !f io d,,i 2— ‘` ' War or Dates
Place of Death ...Hospital. Institution or
Z City, own •r Village 6-f. 4_,C; Street Address
aMa ,r„:.,= Death Natural Cause 0 Accident Homicide 0 Suicide �Undetermined E Pending
LU Circumstances Investigation
W Medical Certifier Name Title
Q iM;G kak.e. C. Ci Kit r c e1 M b
Address ,a i gK
Deat -• ficate Filed C-, District Number Register Number
Cit :Town .r Village ,r. � L+t 5 3 l
Date Cemetery or Crematory
_ f_,Burial UU / i G / , o t Z ,`,l, I/c- 6cM.,--�r
Address v /
Cremation �,,,e__, ��.
s be kJ a t of il..
Date ) Place Removed
Z —Removal and/or Held •
O '—and/or Address
Hold
O Date Point of
Nn Transportation Shipment
Q by Common Destination
Carrier
C Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home A..s,w a he t( }-�q�� 0 a rJ
Address c
_ 7 .. hec,-,c., 4ve (r7- E i _ � rDkl. 2
Name of Funeral Firm Making Disposition or to Whom / j)
a" Remains are Shipped, If Other than Above
Address
CC
it,
Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued f(l f.5- (a°i 2- Registrar of Vital Statistics ,(4 L1
a re)
District Number it 5 Place C 'f', ) AJL-iJ raf' l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- (�
WDate of Disposition it Mill_ Place of Disposition '�1,41L Crfrtibi --
2 (address)
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CC (section) _ (ot number (grave number)
0 Name of Sexton or Person in Char e of Premises t►e,3 -- -)L"4i"
Z , ,c (please print)
W Signature Title et€1i►'i-NOill
DOH-1555 (10/89) p.
1 of 2 VS-61