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King, Joseph NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit f Name First ' Middle Last Sex Joseph k► nq Maio Date of De th Age If Veteran of U.S. Armed Forces, j o - 6-A o l g _ .95 War or Dates 1`/0 1- Place of Death Hospital, Institution or Z City, Town or Village /��l a 4 ,/CL. Street Address 7qq 8/1 Brook Pc' a Manner of Death u Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Untletermined ❑Pending la Circumstances Investigation W Medical Certifier Name Title II ► r�lnt( 3einnih��5 (erre>> � dress L-o nc1 Lc�-ICQ Death Certificate Filed J strict Number Register Number City, owj or Village I nci 'Di t ay1 . .1'_ 0 (D5 3 ❑Burial Date C etery'o/r Crematory / ( ©/ L-/ il $ 1 f Y)� 1i 1 e.l.& C remr Thr /' ❑Entombment Address giCremation Q (-tCe l nkkk 11 Date Plac,6 RemoveH Removal and/or Held 9I—I and/or Address 'I) Hold 0 Date Point of N ❑Transportation Shipment G by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home m , 1 I tr ft-7(n(rct ( 1-4,-o yylc, clog Address � / 3 5 7 WS �-1-C 30 MCI( ak) Lcx, ' v�7 iZ g4Z Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, If Other than Above 2 Address CC il Permission is hereby ranted to dispose of the human e ains des ri d above as indicated. Date Issued t(7 L( 1 5 Registrar of Vital Statistics v" lJ� J (signature) District Number .e 5 3 Place if)d( c v ,Ke___ N ) I certify that the remains Df the decedent identified above were disposed of in accordance with this permit on: Z Q W Date of Disposition/o-S"i i Place of Disposition 1 )At,V,{a C,t<,n•z1�-ry 2 (address) W Cl, CC (section) _ (lot number) (grave number) pName of Sexton or Person in Charge of Premises J c,rA,t y Srj,a;r S Z (please print) I" Signaturey "` ,j Title (.•(c,w,=„1or (over) DOH-1555 (02/2004)