Morgan, Twin A NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name Firsts „ is Middle Last Sex
P iw l u f\ noQcRp
✓ Date of Death Age If Veteran of U.S. Armed Forces,
i 0-1 1 " 1 Z or Dates
} P -ce of Death os it ,Institution or D
own or Village AL-GAOy et Addresstti
LA �lNji ,, (- -A-4
anner of Death Natural Cause Accident Homicide Suicide � Undetermined Pending
Ike Circumstances Investigation
O.
tu Medical Certifier Name
L.e
Address ALMO ( IJV
- th Certificate Filed (n) District Number Register Number
own or Village I'f1-/ 7/
al Date Certreitery or C emato
miiQ Entombment )b -I S- o f-2� I L AT /
Address
g£remation cj J cot/ -tZ- 1�4) cp ut SBL N l 9
''' Date Place Removed
Removal and/or Held
and/or Address
CZ Hold i
0 Date Point of
t
Transportation Shipment
ES by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to IL4fr
Registration Number
Name of Funeral Home N _ f 1 rvit...024s. lO r i O V,o 7?
Address(MD ill V '1�
kJ Al1S �T_ �(�, 4,LJSName of Funeral Firm Making Disp 0 c
Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
w
Permission is hereby granted to dispose of the hujnall r ains described above as indicated.
Date Issued I0--12-7-0 1)-- Registrar of Vital Statisti -
(signature)
District Number to i Place Ln9 b ALgRPy
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til Date of Disposition t D-ic-iL Place of Disposition Rrte a c.c.) CI ,e„ uctol,,)am
E (address)
Ili
CC-01
(section �` (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (fl t n y o elfe
2 f— (please print)
W. Signature cnz, J✓I�y.,J Title Cre rna‘y O;S4-.
(over)
DOH-1555 (02/2004)