Wakefield, John NEW YORK STATE DEPARTMENT OF HEALTH - t, 4 D
Vital Records Section Burial - Transit Permit
Name First Mi dle j Last Sex
Al /
Date of Death J Age If Veteran of U.S. Armed Forces,
S'Y War or Dates
1- Place of Death _
n Hospital, Institution or
ii City,�w r VillageC) .,ee,.,�1+ Stteet Address
Manner of Death❑Natural Cause Accident El Homicide Suicide Ell Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Az, //iJ
Address
Death Certificate Filed District Number i Register Number
City ow Per, �.
or Village( �- f `j''s'7 J 7�
..t
MD❑Burial Date Cemetery or Cre atory
/ 3❑Entombment /,i �7'�� i i^✓("�''I^ . ✓'.
Address A /
Cremation c ,,;F e<J,6ir," /U / 12�0
Date -1 Place Removed
Z❑Removal and/or Held
2 and/or Address
F` Hold
#I
0 Date Point of
t5❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home r✓i ne_y� k O fy I 0(1 J 0
Address I . .94--• CDAny h , + c�„- ,t n
Name of Funeral Firm Makinn/ 1ssposition or to Who
Remains are Shipped, If Other than Above
Address
l L!
P` Permission is hereby granted to dispose of the human remair►g described above a .indicated.
I/2, ..Z)
Date Issued /—3 _,�i Registrar of Vital Statistics ', -.0.-
(signature)
District Number c-K7 Place
/f; /
't—P--�-r
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
ILI Date of Disposition I- 1-i , Place of Disposition ZO j C n-
2 (address)
IL!
tO
CC (section) 'Riot number) (grave number)
ci Name of Sexton or Person in Charge of Pr mises /i '. L_
Sdme'i
Z (p/e se print)
ig Signature Title CIZio
pr76t,
(over)
DOH-1555 (02/2004)