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Monroe, Harry
NEW YORK STATE DEPARTMENT OF HEALTF- . �0 Vital Records Section Burial - Transit Permit NI Name Firs ddl1 S 6// i> Date of ea Age / If Veteran of U.iii".0/Voe: med Forces, /�U a�3 ; S/�j (p 7 ! War or Dates 14 Place of ath 7 Hospital, lnstitutio r fiat o or Village r�""�`/co��7 I Street Address g/A �al/ll/i// A!g„-/ze. Manner of Death rNatural Cause Accident Homicide Suicide Undetermined Pending �I Circumstances �Investigation LtfMedical Certifier Name J Title 1 �fa� a gh C0 h f.9©I"/ Q b 7 7 i%�r.CJ Iii_ /), o -._CAj, oe:9 ce)j/ ifGa ./(/'' (--`7% Oce.0‹, ,,t2-7./A(S-.3 Death C ficate Filed ' District Number Register Number City ow i or Village �"l65,c'/ e 0`2--j I 5c s 41 e Date or Cre tory 4 ` El Burial v l 3 z/ZP l//�iz, C 72efij `//.,/,-- �remation Address Date alicr/<'.e-7 1Place Removed et El Removal and/or Held -. and/or Address Hold 0 ' Date ' Point of NQ Transportation Shipment 3 by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to r-- Registration Number Name of Funeral Hote l r�'/G%/ 14rJ'/r ��1?C- f�G // Address 61-1,a_c--42/7',A//-7 ,.(- -7 /2-1127 Name f uneral Firm Making Disposition or to Whom / "' Remains are Shipped, If Other than Above 411. Address fr Permission is hereby granted to dispose of the human remai described above a indicated. Date Issued —' W�la-13 Registrar of Vital Statistics `" ,. Z sig ture) il District Number 5c, -'-( Place /- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- W Date of Disposition 077-/3_ Place of Disposition -, 1/4JWf2 /4 ddress) CC (section) (lot_numb r) (grave number) 0 Name of Sexton • 'erson in r of Premises �� go`J)j� g CI (please print) W Signature �t Title fg ? L A.SY: (over) DOH-1555 (9/98)