Johnson, Lewis NEW YORK STATE DEPARTMENT OF HEALTH Ilkw ii i 51)
Vital Records Section Burial - Transit Permit
Of Name First JI.Aiddle Last Sex
*.• L-64-)1 5 h 11 r+ ---- -ishosco 1-4ak_
Date of Death Age , If Veteran of U.S.Armed Forces, '
ft L1/2 31 24at3 5 War or Dates.-- q(0 LI 7
."-. Plac: d,f Death Hospital,kistiutiva-Or
City, to or Village (lueetrElouru
Mann-
n Undetermined n Pendin
• DeatIVENatural Cause 0 Accident [314tr:iticiAddderefl Suicidel()ePlu.r* 4e4144) Fac i kV
Medical Certifier Name 0 1
1
True 1.:Circumstances ""-41nvestigation
Kosiyi cxJo-c til)
.1- Address
rAArne_ti 1-rl Ou&L)31')' uni, NI . I 2; 6 LI
......
.iit. Death Certificate Filed ,..\ bistrict Number ' R9Lster Number
4.;_.City, (A 4:Dorn Village (Akttil \OCtrt_i SID C -1 V
Date Cernetertiq•Crematory
El Buda! LI I'1, // 3 - VA.( Via3 Cf-eind-bvi .
_:.:.
Address
Cremation . aLLet.i.,R r V A. Qaten'Sburtid i/VW I .
Date Place Remov
g 1-1"i Removal and/or Held
pi and/or Address
.1. Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
.•.•. Disinterment Date Cemetery Address
El
•:•:-::: ,--,Reinterment Date Cemetery Address
: u
Permit Issued to Registration Number
lip Name of Funeral Home Metylarci --I), bati,( rake ra H-OryLD 61130
it Address
al I I ci-Cetqt0A1e . Ciut.enShan_i , N14- 12cot-1
1 Name of Funeral Firm Making Disposition or to Whom . .
• Remains are Shipped, If Other than Above
i• Address
. .
Permission is hereby granted to dispose of the human ins described a,!):1,as indicated.
Ril
A Date Issued 9 I a<043 Registrar of Vital Statistics -/ C- ._ G. L.,
, ..)(11 A---
Mi
(sign,Vil
Dis• trict Number _oc / Place ,(Th(....--,r, 0 )
...
I certify that the remains of the decedent identified above were disposed of in acc ce wi this permit on:
i Date of Disposition & 24-(.3 Place of Disposition 4:70,100QW(address)
-
(address)
lib
Cf3
(section)Es ictr number) ( i, (grave number)Name of Sexton or Person in Charge 1 Premises AO -34%atr
Ci
:1.:.: Signature (tf L. --4---7-- (please print)
Title C Willa-
(over)
DOH-1555 (9/98)