Jordon, Jay NEW YORK STATE DEPARTMENT OF HEALTH :4 .,y
Vital Records Section Burial - Transit Permit
Name First iddl L st Sex-7^///'{
Date of Death Age If Veteran of U.S. A ed Forces,
71,A S/f i- '-') War or Dates
14 Place of Death Hospital, Institution or
• Cityttit , Town or Village Street Address 72 �c,c3o Kd'
Manner of Death Natural6 C u 0 Accident 0 Homicide 0 Suicide riUndetermined ri Pending
l Circumstances Investigation
iti Medical Certifier Name Title
0 AA, // f'‘,--o //)
Address
ft '‘6 SA X t) b Fl4 Ina,
Death Certificate Filed District Number Register Number
City, Town or Village 5 7 5^0 .0V-`
❑Burial Date ` Cem tery or Crematory
imi❑Entombment 7i 3 ol, c— �j� 4/.,.e,e.K0
Address
`� KL�' `�
giii []�Gremation
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
1)
119 Date Point of
g'0 Transportation Shipment
.0 by Common Destination
Carrier
Q Disinterment •Date Cemetery Address
Q Reinterment Date Cemetery Address
N:iPermit Issued to Registration Number
Name of Funeral Home ..> . 4.• I<4 '7t2CU 0 L C3 7 7
Address / 3 11/A-eicalpie-e, -7-2 Co2. f
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
lit
9. Permission is hereby granted to dispose of the human remains described above as indicated.
gil Date Issued •13O ,aw5/ Registrar of Vital Statistics . J `-r-k.k -
J (signature)
€': District Number 5 7 5 Place i ,ve. k .
• I certify that the remains of the decedent identified abo a were disposed of in accordance with this permit on:
Place of Disposition e>Y y
t� Date of Disposition ->�c�--'l� p �,�I� j��.J ��i�
(address)
in
CO
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises J eAyytey Ste,fc,.S
(please print)
Signature ,,,
I �' Title CCe.»4 G r
r
(over)
DOH-1555 (02/2004)