VanWormen, John C ; t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiiiiill Name First Middle La t Sex
` `
Date of Death Age If Veteran of U.S. Armed Forces,
9 - 3 - a_pta.. 60 War or Dates
I Place of Death Hospital, Institution or
Gay, nor .- ,�h Street Address a f &t V ),T.
Manner of Death IN Natural Cause D Accident El Homicide ❑Suicide ri❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifieral Nage s Title
'` Address Z
1o0�I R
iiiii Death Certificate Filed District Number Registe Number
€ City, Town or Village Y54"1/
Date CNemetery or Cremato
.. ❑Burial _ y - J .s.>S.
Address
®Cremation G, �
Date lace R` emo'4ed
2❑Removal and/or Held
2 and/or Address
• Hold
Date Point of
N• ❑Transportation Shipment
Gl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'':<' Permit Issued to Registration Number
Name of Fu eral Home cs. O U Lk y
iiN
Address
e] Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
I
in Permission is hereby granted to dispose of the huma emain described a indicated.
• Date Issued S'- y / R Registrar of Vital Statisti ( -
(si ature)
.iii District Number V(5=2 Place ( xN
iiiI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition ii"/2 Place of Disposition Pl i., YII�" W2.6,4-+pgy •
a (address)
W
fR
CC (section) (Jet numpe (grave number)
DName of Sexto or Perso ' Charge of Premises 5t -1- ("- I a
: (please print)
t! Signature Title (-67.44-b917/ /(}5Ste
(over)
DOH-1555 (9/98)