Mitchell, Sr. Joseph NEW YORK STATE DEPARTMENT OF HEALTH /S-j
Vital Records Section e ' ' ' Burial - Transit Permit
Name First Middle Ai Last S
7-v 60-P/4 tJ /cdr0/1 / f/7-01,/ Sn.. . /7e7 6--
Date of Death Age if Veteran of U.S.Armed Forces,
si Z./ /L 7(( , - . Dates / 9 3-3 - / 9i
of Death GI'
� ospital. titutio
.1 'own or Village t b�.is I-",gi e. f Street Address (t,c-,,,)s 1`1_ s M et??3Z
a tanner of Deathr-,Natural Cause 0 Accident Ei Homicide 0 Suicide riUndetermined n Pending
tit
0 Circumstances Investigation
I Medical Certifier Name Title
Ct
Address
16 2 1" Iv C Lt ' Fz ldf I Z coo f
D Certificate Filed _ District Numb i Reg r umber
C. , own or Village 6,�",.) S' Ozt,S
Burial I Date Cemetery r Crematory
i2 2 l Z } ( LA-..)�J cc L/�
❑Entombment Address
remation U t,1C Lti—. i' Q 06 ,J3 Q
Date PlaEe Removed
UVL7/
Z Removal and/or Held
O and/or Address
1.-r: Hold
O Date Point of
11.Q Transportation Shipment
a by Common Destination
Carrier
El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Ho,,/na -0, fSca.,er Rtxiirc -1 'Ko:` - 0I l 3o
Address La CkyC iie- SA". , t.-leC.IZS r`! , NI e v...s /or V 12 C)
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
Address
ix
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II. Permission is hereby ranted to dispose of the human remains d ribed ab ve as indi ted.
Date Issued / /,� Registrar of Vital Statistics JQ��-,
JJJ (signature
District Number 6 ®/ Place _1 /&..$p/
I
t- 1 certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
Date of Disposition 5/j3/it Place of Disposition Route. Li orid,...-
a. (address)
tli
to
(section) .(lot number) S (grave number)
Name of Sexton or Pers in Charge f Premises AlS4TIvr-
1:je Arrl'J-
Z ( ease print)
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Signature �? Title C a k IV)A-1Thk
(over)
DOH-1555 (02/2004)