Loading...
Johnson, Rollin NEW YORK STATE DEPARTMENT OF HEALTH ` b Vital Records Section Burial - Transit Permit igi Name \.c.) \\` EMiddle Lases--�_ (51\ Max Date of Dg,q,th Age 1 If Veteran of U.S. Armed Forces, r" 1 ext ) 4 (Zj 5 War or Dates 14 Place of Death° Hospital, Institution or ,�) /� p City, Town or Village CS_ILIStreet Address 5 7 1" S�"� 1`z' 0 Manner of Death©Natural Csase 0 Accident 0 Homicide 0 Suicide Undetermined Pending Circumstances Investigation 0. in Medical Certifier Name r.,......., Title ,,A.D - Address a :� PA-rPf- 66,7s Tom, N,( t go! Death ariyate Filed 7,,,-- ) District Number �\ ,"� I`. t Register Number 0 t Ci ovrnVillage '; '['Burial Date / aCemetery or Cremato S,( 3 / o/'. 1 ,a.- v:c_.,... 6^4s r s 0 Entombment Address . Cremation be,.-k.C,e.„, J-" / )c ,ar�_ - Date 1 / lace Removed Z Removal and/or Held ❑and/or � Address £1) Hold 0 Date Point of hTransportation Shipment E by Common Destination Carrier Q Disinterment Date Cemetery Address. Mi El Reinterment Date Cemetery Address • Permit Issued to Registration Number mi Name of Funeral Home Gvt.S ,, r-(_ --F--' cr4 1-1m7 00 Sys Address oi iiv et`Akim. At,c_/ r,.t.tk. / 1 ' '-''' ra 03- Oiliiiiii Name of Funeral Firm Makin 9 isposition osition or to Whom Remains are Shipped, If Other than Above 2 Address IX Ili :tiii Permission is hereby granted to dispose of the human r ains descri ed above as indicated. Date Issued tW"dc�- Registrar of Vital Statistics �� 6 , (sign afure) >` District Number kJ Places C. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LEI Date of Disposition 5- l-t, Place of Disposition C odes 2 (address) list fill I (section) 40.1t number (grave number)Name of Sexton or P son in Charge of Premises �e'`^�� 2 lease print) (uiiiSignature L Title atfiliOrliC2 (over) DOH-1555 (02/2004)