Brooks, Joseph NEW YORK STATE DEPARTMENT OF HEALTH tf
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Vital Records Section -,. Burial - Trarit Permit
Name First— Middle Last Se�
jJn5Qfh LObY7 ' 13roOK5 ///
t::!,, Date of D th Age If Veteran of U.S. Armed Forces,
!3//Z o 9 War or Dates A-)0
14 Place of eat h Hospital, Institution or 1/
g p Z -L.l Jc, A105F
Z City, Town or Village Street Address
ck Manner of Death ` i C A� Undetermined Pending
Natural Cause �Accident �Homicide 0 Suicide � �
LLI Circumstances Investigation
id Medical Certifier NameTitle
0. ?ever . (,L 1)beo/ 12i 0)
Addres
i 24 koSF Rd. Sc/3e ifCr_ IN7
Death Certificate Filed District Number "-7 Register Number
ga City, Town or Village :, 1
iiiiE 0Burial Date j / Ce etery or C' e/matory /�
DEntombment
/ /Y7/2 . / ery V / e7) CrE.fl 17 4 7a Ry
Addres
> ACremation GL eru ii tC /) Y
Date Place Removed
gEl Removal and/or Held
and/or Address
w= Hold
f4
Date Point of
finCL 0 Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registratio ber
:,:,„„„.
Name of Funeral Home m 6 CL,r� --loc., Q i d?4
; : Address
M: 3 JO g A rA A)Ac 1'1\1 . LA K e PI.RCI d
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
r
Permission is hereby granted to dispose of the huma oains de a as indicated.
Date Issued Registrar of Vital Statisti e24,1 ,�v '�'�..�
(signature)
Wii District Number Place
>;>.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition i/AOAtPlace of Disposition Re Vc&, CrO-c or a,`
(address)
COiti
C (section) /1 (lot number) (grave number)
Name of Sexton or Pe on in Charg of Premises C h`i)�y — J th4ttt
j l (please print)
Signature l_ Title a et A
(over)
DOH-1555 (02/2004)