McDonald, Keith NEW YORK STATE DEPARTMENT OF HEAL11H-- 4 LI d
Vital Records Section Burial - Transit Permit
Name Fir t Middle Last . Sex
/1. / /ii �: / tip k Aid i l
Date of Death Age If Veteran of U.S. Arme orces,
Eiiiii S- - 03 /�- 5-$ War or Dates /t'0
1 . Place of ,ath Hospital, Institution or
City, own r Village G L r,0.�,ii- ` Street Address. -.:-ry W I/ It'J�1�'
Manner of Death❑Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
111 Circumstances Investigation
tu Medical Certifier Name Title
c C . F-Atic-3 VP i A fii-0
i.10rbei. 90 4Pk- P/Aqa NI". i 9 if6
Deat fica Flied - / District Number Register Number L.
City, or Village SC f' j.-d-r1 l i I
iiil❑Burial Date Ce tery or Cremato c ,
''❑Entombment t✓, a -;4/ 2--- //c L`1 et+1 C,"i-e r47A`tt kr
Address
gi P1CLemation G" t'A)S.4 v• ( A.'% 12
D J
bli
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
H Hold
C
0 Date Point of
rk 0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Qi Name of Funeral Home Gi:`P+ / 1,. 6,UE r-j ( /Iv � er_s f
Address 4 r 1 4 P/:__ oy . i D /o `c0 70
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Lt
tI
9' Permission is hereby granted to dispose of the human re ains described abov as indicated.
,
Date Issued 68460/�._—Registrar of Vital Statistics ��� 2. a
(signature)
District Number /54y3 Place St....,4 yry 4 A�� fU i is t')Q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition li -i.-tt Place of Disposition {inlitw (,- - rut `
2 (address)
UI
CO
l (section) 4 _ (lot number) (grave number)
ta Name of Sexton or Person in Charge f Premises r'i _,t'^�I
Ztkii
( lease print)
44
Signature Title Car_wl
(over)
DOH-1555 (02/2004)