Brown, Harold NEW YORK STATE DEPARTMENT OF HEALTH �(
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
1MR 0-2 r� MALE
Date of Death Age If Veteran of U.S. Armed`F9rces,, , , /
-}I11f01-9l 4hO/J-- 90 War or Dates /97T - / ! T
Place of Death Hospital, Institution or
City,•Tewn of-ViHage (2)S 42,5. Street Address 4-6e•A,s' 192.1,s kidsP/7/ L
Manner of DeathONatural Cause Accident El Homicide El Suicide nl Undetermined ri Pending
its Circumstances Investigation
ut Medical Certifier Name Title
i i' .HA) , yam - �
Address /(p/ 44 a-cx.1.5wcy,e43,,
PIMA) - - �.1 y l�
Death Certificate Filed C District Number Registe/lr��umber
ow City,'Fn-e Wage-
r age- -ZL 5 / '7`0
DBurial Date / Crematory
t 3/ ,40/off-- /7V L /6c3 etc-19,1.mei�nt •
:, ❑Entombment-Address 1
P,,remaiion__
/ Q /cr AO SgU J -9? , ia-k-o*L
Date Place mo uE /L Reved
iiRemoval • and/or Held
{ ❑and/or
i Address
Hold
0 Date Point of
05 Q Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date • Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registratio/nNumb
Name of Funeral Home , 7 - tiC, fi L A'6", //U -, 0/G c-
Address e-6- 60g / li j `' 's
Name of Funeral Firm Making Disposition or to Wf om
I Remains are Shipped, If Other than Above
2: Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Ri Date Issued7N, 3/, /z. Registrar of Vital Statistics
(signatur
District Number 6
56o
) Place t.sR,.I•-S F t t cr A y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ul Date of Disposition (J3)1r2 Place of Disposition ,t.U....., (r c'tocw.:
(address)
I:
U)
CC (section) 4 (lot number) r (grave number)
Name of Sexton or Pe on in Charge f Premises cf s-1 +- J i!'I NA
10 (please print)
10
Si 1tCEM1'ai��0gnature Title V
(over)
DOH-1555 (02/2004)