Dingman Jr, Francis It ..# S 6 I
NEW YORK STATE DEPARTMENT OF HEA.6,TH_'Ng.
Vital Records Section Burial - Trandit Permit
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Name First — Middle ,N Last I c 1 S
C- /7 e 43 i Ai c."/.6J r . 1 /76t-u -
3—e .
n Date of Death I / 1 Age 1 If Veteran of U,S. ArmeclFiorces,
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.:i..: ,1e1,3) /ty___ ; il 2_._ , War or Dates, K o it:06W
Placrt..ii7th Street
Ata106dnsretsitsutioNor c---)
..f.,ZI. .. City Tow r Village 0 06123--ilsv a tri /Itor '7)-)0,0,770,.._) A LA/ks 1„,-G,_
is Manner of Deathtural Cause Elbcident ri Homicide 0 Suicide El Undetermined r—i Pending
•-p ' 'Circumstances `—'Investigatiorj_4
t Medical Certifier Name Title
y
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Address
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/S-2--- Yk-61-‘ /-11 0 lic.?- . Ottg-ALs Fose-rs Ay /2,Po cf
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DeathfoAf icate Filed ,-, ',-- .,krictp)..irnber I Reigister umber
0, City,(Towri)dar Village Cs2 06-er g 0_7 i )6
. . I Date / I Cemetery or ren(--i- xy',/)
r--1
LJ Burial 9 2 iy rl it - a 6-1 )
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1.2 Ternation 75k Address
____LLuxiie___ ___ i1S-A.F.3143 Vyt7_--- y
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Date , Place Removed
Z ri Removal and/or Held
_
i= and/or Address
-; Hold
CA
2. Date
, Pontofi.
13 0 Transportation ; Shipment
25 by Common Destination
Carrier
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Date ! Cemetery Address
D Disinterment
Date • Cemetery Address
::: 0 Reinterment
Permit Issued to ,, .D k: I Registration Number
.%; Name of Funeral Home Hayna r c/ 6- 00-Aer Fi----Lne(a/ hocnc---Address ii Lan, ,j_./ , s., " 1,, A i . Li I/ i 1 yozi
1 ct-i•1 clic Lir• , bakcc.nskA-Ltcj , ',Jew iorp-
LAI Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
Address
ill
M Permission is hereby granted to dispose of the human emains describe above as indicated.
g Date Issue biA)1\--1 Registrar of Vital Statistics ---(2t. 1..A.___
II r (sipo,kre)
,__.District Number c(c)"c--) Place 1 n Lt.., -N
.:.1 I certify that the remains of the decedent identified above were disposed of in ac rdancp with this permit on:
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5 Date of Disposition el/44/ Place of Disposition elwi„1,.... i--itiri.....-
a (address)
tu
to
cc (section) (lot numbpr) (grave number)
° Name of Sexton or Person in Charge of Premises
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z (please print)
41 Signature // .4....,-- Title Con MTV(
(over)
DOH-1555 (9/98)