Vaughn, Kevin 3 L(NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records Section Burial - Transit Permit
Name First . Middle Last Sex
/1ft/A/ iJ , f//14(15-Ai/(/ h//9-Z-
isi Date of Death Age If Veteran of U.S. Armed Forces,
2/c— /2_ v War or Dates ^/C)
g Place of Death Hospital, Institution or
City o ' or Village Fat?T/q-4/AJ Street Address//2 4079pojodp RGc//G L. Gv �/
to
ci Manner of Death❑Natural Cause ❑Accident ❑Homicide ,Suicide ❑Undetermined ❑Pending
i Circumstances Investigation
Medical Certifier Name Title
m/9-x cRosSh-7 / mD
Address
..... Death - ificatewTZJ/7`/ t3L L ✓ X/L- o 1'X / c'-P 2
R;ii Filed District Number Register Number
>`s Cit , Tow •r Village FQ f'7- /9 /A/ -.5 ..Sr
Date Cemetery or Crematory
❑Burial �— /�o -g0/ .. 6'//(/ ,/67 y CHZ9V/97D'/(/rt
Address
®Cremation /.s'1c,Z�/s d3aR /5i�. ./4'0P
Date , ,' Place Removed
0❑Removal and/or Held
••• and/or Address
• Hold
Q Date Point of
N❑Transportation Shipment
C by Common Destination .
Carrier
.::: ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
in Name of Funeral Home/? /9,$yQ/ti/ �/f,/ �J9Z •�76 4///-
€ Address
R o . d3oY 7 FoR7 19-A/4/ A/,V /1 cio2 2
iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
in Permission is her by
granted to dispose of the human remains described above is ind)cated. /
i Date Issued 7 /'6//registrar of Vital Statistics I • GL (' -r ,' / �': �f
(sign re)
L
Place , ilk 7 C.c, /2 S'.._7
>��� District Number ��s� ' ,�- ��-�j'�� /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1 p -
E Date of Disposition 11 fl I IL Place of Disposition 47:1•411 trw C tdriu..,
2 (address)
i ii
N
cc (section) (lot number (grave number)
GName of Sexton or Perso in Charge of Premises k r k- r -e qff
z (please print)
> SignatureA Title OLE h►14tU12
(over)
DOH-1555 (9/98)