King, Loren NEW YORK STATE DEPARTMENT OF HEALTH +I 37
Vital Records Section Burial - Transit ermit
Name First Middle • Last Xihe lc
Lo(- p �" i I n 01
Date f eath Age If Vetera f U.S. Armed Forces,
1 13 5q War or Dates IC(SS
i-- Plact_oLeath ll Hospital, Institution or
Cit Tow for Village )(}j I a n La_k Street Address 124e Lane_ B i rGh r
W Manner of Death r Natural Cause Accident Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
iii Medical Certifier Name Title
Chrls-�-Dpher'Jac,Kc Dn ReG
1 La
Death Certificate Filed District Number Re ister Number
City,lfowta.or Village I nA f a n I ctK , c�0 5 3 /
hil['Burial Date I C eter 9r Crem tort'
❑ Al
��5(2Q13 ne.ViceLJ AserY1
Entombment Addre
_ '2]Cremation CU uec.n 5 b U 9 N /
Date Place Removed
Removal and/or Held
and/or Address
F_ Hold
to
Date Point of
❑Transportation Shipment
d by Common Destination
Carrier •
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ( Registration Number
Name of Funeral HomeMI �i rpm l 4-1,0 rye 0119 9
Address 4 35 ,] 8l Q._r' kA 30 1 ,\01( I , Io y )?.g V z_
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
c
LU
` Permission is h reb granted to dispose of the human ma s describ ab e as indicated.
Date Issued , Registrar of Vital Statistics JJ ,, AA ,,
signature
District Number —) 5 7)Placemill n n o 65<fC`� Q
I certify that the remains of the decedent identified a ove were disposed of in accordance with this permit on:
al
Date of Disposition �- $y j Place of Disposition r ern.. cf t...
a (address)
in
W.
CC (section) '(lot number) (grave number)
Name of Sexton or Person in Charge f Premises rk, c Slhfllt
2 / (please print)
1. Signature �L I ..'� Title CNi(ea;
r
(over)
DOH-1555 (02/2004)