Jenkins Jr, Lester NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
"' =`= Name First Middle Last Sex
<:< Le..S\s-t-x' CZ Acir—NV-rs _Ns--- in
Date of DeathA e If Veteran of U.S. Armed Forces,
‘a l l7 aO �3 �• War or Dates
.. Place of Death Hospital, Institution or
y . City, Town or Village Sc.koco, 5�., s Street Address SCr-cA-oSe., cR., 4�
Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
Circumstances Investigation
14
• Medical Certifier Name c ` j� Title
mii
Address} f c , e ` ^� r,� / r
pi all �.�,Jr�� SAf JC C Sct-`,. s 1V a V uo
?t< Death Certificate Filed District Number JJJ Register Number
iiiiiii<_': City, Town or Village jd( S7 c
Date emetery or Crematory t
❑Burial ')$ 1D Vim vit, Cre:"-(0-40's6 .
Cremation Address
( .Lc-. .r mad Ov�e., .--� 'KVA la-soL\
gDate Place Removed
❑Removal • and/or Held
�-- and/or Address
ti Hold
0 Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• Permit Issued to ` Registration�Number
l` Name of Funeral Home rDe�15 l [r t_. rov e r �` w'e_ C�7o�-t
N: Address
.S\ -r- ... by t C-Or-\` ' ►. N `k aS D:Z
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
iall Address
i
il Permission is herby ranted to dispose of the human remains deg�r,(�, ptioi ciicated.
RI
gi Date Issued j Z 1�6 l Registrar of Vital Statistics Hw1ttEE►► uwA15 ttiitt ((aaSS
>r< n re)
{gg District Number 1-1S01__ Place (10-2reN 1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1 �
i Date of Disposition it/ of i3 Place of Disposition -',na' Jyw a-atom.,
(address)
ial
(section) (Io numberr�I (grave number)
g Name of Sexton or Person in Charge of Premises �,j ,__ ifi�VI
(please print)
W � P )
f; Signature Title air it e
(over)
DOH-1555 (9/98)