Buckley III, James NEW YORK STATE DEPARTMENT OF HEALTH �VI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
/4M S J (JCICL e Y 214 M
Date of Death Age If Veteran o U.S.Armed Forces,
vico 1�3 ? War or Dates
%••; Place of Death / Hospital, Institution �.y� /�
WCity,Town or Village City of Albany _ or Street Address �,�,'�l Modir a,/ t: Pr1 /— _
Manner of Death Natural
❑ Accident ❑ Homicide ❑ Suicide ❑ ndetermined ❑ Pending
111 Circumstances Investigation
8 Medical Certifier Name s Title
o 4 ewi she 1 Z tQy\ /416
Address
IOC d A A11 /
SC I) 1a District Number �T Register Number
y; Death Certificate Filed
City,Town or Village City of Albany 101 /c
Date p� Cemetery or matory
❑ Burial 4/v/ai/3 i'n e 1 i)4(A.) CIP‘rna hrv/
❑ Entombment Address !
Cremation
( vk e e n s bun)/ 1 Ai K
Date Place Removed
Z ❑ Removal and/or Held
9. and/or Address
Ih Hold
Cl,
Date Point of
O.r' Transportation Shipment
Cl) ❑ By Common Destination
p Carrier
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
CI Reinterment
Permit Issued To �,,/ /� / Registration Number
eC.y
Name of Funeral Home JQ y-0) 1, , ,`P 11/ f N 00C/
Address
ri7vn )-a 6, .r/ r f,2 x-70
Name of Funeral Firm Making Disposition or to Whom
Fes; Remains are Shipped, If Other than Above
2 Address
w
Permission is hereby granted to dispose of the human remains descri ove s' cheated.
Date 0 -/e--�C�/`3 Registrar of Vital Statistics �~
Issued (si ature
District Number 101 Place Albany Police Departm t City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with'this permit on:
l--' Date of Disposition QI Ll Ul3 Place of Disposition PSI�qd Cr tor'ir+--
u (address)
2
w
re (section) (lot n ber) Seft
(grave number)
0
S xton or Person in Char a of Premises r,)1r'
W Name of e g
L. (please print)
Signature /,(,(E Title OXMAtt
(over)
DOH-1555(02/2004)