Joiner, Leonard NEW YORK STATE DEPARTMENT OF HEALTH ,, 4t C 2
Vital Records Section Burial - Transit Permit
Name First ,t A,Middle Last Sex {ley
L XJEJ� "1 /Ulzt y --3 o, JLT h }
..� `><< Date of Death Age If Veteran of U.S. Armed Forces,
1 _ 1 ;70 1,cc" q I War or Dates IA-NW Z-
P e of Death Hospital, Institution or v P5 , a4 Dx $ i.
own or Village r7AC'O-S1 Street Address c pI vt_ic-� r y (-uorp
0 . ner of Death — Natural Cause ✓Accident 0 Homicide Suicide C Undetermined — Pending
la Circumstances —Investigation
tu Medical Certifier Name i� Title
Ct ,�G ll i I Ik C` c t avert-- 114:
AddresA
( GO 'i., Q-�u to i.?C, t ti --r• . k'uS , /Uy ►27Z l o
iii D th Certificate Filed ®,-oNuAbA dc'riJ-iI District Number Register Number
>i. Ci Town or Village ,�`> t
Oi Burial Datat` leg-7.f, ii( ` i fit V bdOhmetery al..E14tt►°rpP-y
❑E tombment Address � �/ •
i Cremation Z 1 VgvAA-A,
:) (PU 1s6vit ) Nj l 2SbYe
Date Place Removed
• Removal and/or Held
▪ and/or `Address
Hold
5 Date Point of
Q Transportation Shipment
at by Common Destination
Carrier
;> Q Disinterment Date Cemetery Address
Date ' Cemetery Address
El Reinterment
Permit Issued to r Registration Number
Name of Funeral Home M,ij-Vj try tz- ► UNaz d -tribwf- 0(011
Address A
r2 VA 4(IJ 'T•I indLt f IJ' 1 ()1
pig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;;' Address
w.
" Permission is hereby granted to dispose of the human remains described above as indicated.
Op Date Issued 1-1 l zO t S' Registrar of Vital Statistics (signature)
District Number Place 0 - o J-D fi A -ow.i t-t/ \) I -- Ir' Gp R"IN,r
el
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition if i$li$ Place of Disposition .FrM(i✓ �,,,,-4.,.,
(address)
N
(section) � (�ot number) (grave number)
•
Name of Sexton or Person in Charge of Premises i<nt �� �i.^tbC
i« (phase print)
Signature It -/.�' Title aitolti.L
(over)
. DOH-1555 (02/2004)