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Maxam, June in NEW YORK STATE DEPARTMENT OF HEALTH. 41 La Vital Rem Section 4 ._ ,. Burial - Transit Permit Name First Middhe . Last Sex Jury 1-\ax.awN - Date of Death 3C] 3 Age [ If Veteran of U.S.Armed Forces, War or Dates `:'f Puce of Death ,Institution or e , own or wage C7lens \�,s street Address Glens '�-a\� :'\bS�,- ` � ^inner of Death w Natural Cause ❑Accident p Homicide ❑Suicide El Undetermined ❑Pending }5; . Circumstances Investigation Medical Certifier Name Title Gama\ fir- •h s,c`,an Address \D0 Cto,r S -Cets, ( \exns \\t - \Z8o1 [�� 4 t Death Certificate FtlIed / �N DistrictNumbercoo �Number City,Town or Yee �i ` . (�/��/VJ ❑ Dam i D i ;1 )Z0► 3 Cemetery . RI nr\'%ems Grime y `: Address= ►1 Cremation C xCec1SSbve 1 y , 3N( \2(6O9 Date Place Removed 0❑Removal aixtlor Held and/or Address = Hold sri Date IT-point of E0 Transportation Shipment 3 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Beni Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Ha ynard b. maker Fuiteca-i iomt~ 01130 Address 11 La a.y to c+. , C ut ensbLu-cd,A i eAw ' rit Ja Soy Name of Funeral Fwm Making Disposition or to Whom -= Remains are Shipped, If Other than Above Address N Permission Is hereby granted to dispose of the human remains described above,as indicated. Date Issued%©` 3 c C f 3 Registrar of Vital Statistics .ADC.,c.k_,),,..C.. L/O (sum) District Number 56 o r Place G(•,i-,s pr.. l 1 s, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i EDate of Disposition if /I ID Place of Disposition eLi.✓ CwNT,itee/0-- (address) SA e (section) number] (grave number) Name of Sexton or Person in ge of Prim S,-�fi i J Q nNt1 Z (please print) gt Signature 7L r G 111- (over) DOH-1555(9/98)