Dean Jr, Alvin it S1S—
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name` First Middle T Last S oi4
Date of Death AV/AICAge If Veteran of U.S.Armed Forces,
-14 c1(Azesfy sy War or Dates
1- Place of Death Hospital, Institution or
W City,Town or Village 6) ga�Y Street Address /% Q, 9A/ O0A'/UE_ & y' Ny/ddDy
`p Manner of Death rut Natural Cause 0Accident f Homicide 0Suicide Undetermined Pending
Circumstances Investigation
0 Medical Certifier Name r. i Title H P
Address C,Q L pt,p C4a.)c.C.. , teN7.412
f() iJ09.e Ik S7 (s-.( -' i s3cc-& Ai • .61ed /
Death Certificate Filed District Number ., Regist N ber
City,Town or Village �C i+%S�cc,e y sc�
❑Burial Date If Cemetery or Crematory t
❑Entombment ��` � 8/ " " nst 0 iE eJ c 4' �1d Q to
Address
Cremation c?/ 6A.Lia )F-& )9L LA, .3u22y Ay A? ?7J L/
Date Place Removed
Z Removal and/or Held
p' and/or Address
N Hold
O Date Point of
.N 0 Transportation Shipment
0 by Common Destination
Carrier
y 0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to /` Registration Number
Name of Funeral Home dtO/.tF)` f/Y ',C- _ j gas-
I-
Address
`3 6 ` ' Ae
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2 Address
CC
W
a.: Permission is hereby granted to dispose of the human remai s cribe i 'cat Date Issued �'j -1— t 1 Registrar of Vital Statistics G4
� / (sig ature)
Tifi District Number S -1 Place ' t
i
HI certify that the remains of the decedent identified above re disposed of in acco ce with this permit on:
Z
Date of Disposition •/$f i Y Place of Disposition .2 ., e Fes..
(a dress)
Ui
Cl)
cc (section) lot number) (grave number)
p Name of Sexton or Person i Charge of Premises 6/i ' h&
it
`7 (please print)
W Signature C'L Title CP/M
_ 9
fygit
(over)
DOH-1555 (02J2004)