Bump, Frederick Cfg
NEW YORK STATE DEPARTMENT OF HEALTH - b
Vital Records Section Burial - Transit Permit
Name First Middle t Sex
HeJ.tvstc lL /Y uYn p r4i
Date of Death Age , If Veteran of U.S. Armed.Forces,
Mil /2 , a 9 L3 War or Dates .? 1l Y‘
} Place of Death Hospital, Institution or Ad10-e,da.4-t'- Ti.` co . it?urs/ Nam_
City, Town or Village i,jv 5601 Street Address //j., 31' f�c�v / f? L
tzt Manner of Death Natural Cause IOU Accident El Homicide 0 Suicide D Undetermined El Pending
tij Circumstances Investigation
tu Medical Certifier Na a Title
Au1 4/1 iv 6. rigD.
Address I /V, .g /l ' ✓ 0w / l_Y N0-1 Uwi Z'f Q /` 7o2s--51-3
Death Certificate Filed District Number ,. : G�Register N l er
City, Town or Village r"'+o/iyt,.5 A uv
:,i,i,,,,['Burial Date 7 Ce ry or Wmatory
[]Entombment id2.----.56 ag/A /N 2 vt j nre,4-7 ! -)- J
Address ,,"
emation (XU2ex). -6v1,2/ PY7 -
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
tii Q Transportation Shipment
O by Common Destination
Carrier
j,> Q Disinterment Date Cemetery Address
:': J Reinterment
Date Cemetery Address
Permit Issued to A/ � Registration Number
Name of Funeral Home 2zQ rj I-, , A * f L joCitn ( IIc_.. d-tr.'!Y
Address
Oci\-----(9-0-\ 4 tild' it-:)( / 70
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tt
tti
:,` Permission is hereby granted to dispose of the human remai s described ve as indicated.
i Date Issued la.,*,-- L3 Registrar of Vital Statistics " a ,,.
(signature)
District Number ( Place 7: ��� S e 0" w
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Date of Disposition I I.1 11,5 Place of Disposition ,�; ;v, C
(address)
0
CC (section) (lot number) (grave number)
Name of Sexton or Person in harge of Premises 4 r h
.:. I (pl ase print)
i Signature 1 ,_ Title O2 PV(
(over)
DOH-1555 (02/2004)