Warren, John NEW YORK STATE DEPARTMENT OF HEALTH - 41 -737
Vital Records Section Burial - Transit Permit
mll Name First ei Middy ,L E ei�� Sex
H
Date of Death_th 7' Age 'VAV/ If Veteran of U.S. Armed Forces,
�—a 3— 6/3 7 War or Dates /g53 ,- 27
Place of Dea g. (1,2,-)t,141
Hospital, Institution or
- .- _.7...: City, Town �� Street Address J
Manner of Death E Natural Cause ❑Accident ❑Homicide ❑Suicide �❑Undete fined ri❑Pending
Circumstances Investigation
Medical Certifier Nam /JCl/J'L
6f‘171'4(-- )c
Title ��� rtg:
Address <� %
fig Death a cate Filed Cry / District Number : Register Number
S< City, �r�fr r.: -.- %�iy�� 7�
Date �► Cem or Cre o�ry� ' )
❑Burial ."-.4s-—o d/3 U�✓A--a-/ (C.GU ( ,- J2 -
::::: Address[ Cremation 4�',,,L' 9 j 2��j
Date Place Removed _`
8❑Removal and/or Held
and/or Address
rA Hold
Q Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
❑Disinterment •
❑Reinterment Date Cemetery Address
Permit Issued to Registration iN�umber
mi Name of Funeral Home/ix_
�_,nte ��f ,�e 7- fL le
iE
Addressaiiiii„.7„,...._a.
/� ® � IL/ Sfr�I" A��/
Name of Funeral Firm Making Dispositfn or to Whom
14
Remains are Shipped, If Other than Above
Address
al
1
Mil Permission is hereby granted to dispose of the human ains described above a nd. ated.
iiiiiiii
Date Issued /2-6 S- egistrar of Vital Statistics (gym ! �
iature) _
District Number 57a3 •Place d�G1� / '�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
l Date of Disposition 12-6 13 Place of Disposition sli..) C ,,._
;; (address)
iU
Cl)
CC (section) t nu ber) �` (grave number)
GName of Sexton or Person in Charge of remises , liti✓` .Vs,i44‘fi`
g (please print) pI
4! Signature4 Title OiEmp'�
(over)
DOH-1555 (9/98)