Johnson, Mark t # 7 L3
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NEW YORK STATE DEPARTMENT OF HEALTH Burial � TransitPermitVital Records Section
Name Fkst Middle '"t_ast =_Sex
Date of Death ri i Age m__ If Veteran of U;S. Armed Forces,
LA" \ —\C SCV I War or Dates
r—
te.: Place of Death T Hospital, Institution or
Z City,Town or Village ; Street Address
Manner of Death Natural Cause [Accident P-Homicide [ Suicide U Undetermined Pending
Circumstances Investigation
La Medical Certifier Name _- ___ Title
Address �� r,N....
. Death Certificate Filed .e A Nu
m Number Register am __.w
,. City,Town or Village 1`\6 C-C_O- 3 I g 5 Co 2 I Y
®Burial Date 1 _ Ls\ ^ \c6 = Cemetery or Crematory hoc`
�Enrosnb►nent': 1 P.\ - \ 'eC.v.. C - `'
. Addis
Cremation Qn ) . s\-‘
_................w�ON-er- � Qv '� __
Date I Place Removed y
Removal ' and/or Held
and/or Address
.§7
Hold
Date I Point of
Transportation s Shipment
`G by Common Destination
Carrier
Dsin#erment Date Cemetery Address
Lj Reinterrnent
Date Cemetery Address
Permit Issued to y�I , C Registration�7 Number
Name of Funeral Home 1`l ! .... 0\d 1.... ......
Address V C \(`6`'eN .\\ , S\�� Gk t—AS L\Vj t\ t
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2. Andress
i
Ul.
Permission is herebyi cep
granted to dispose of the human remains described above as indicated,
Date Issued 9I t/1/ Registrar of Vital Statistics `'"Z' AA_ , r( d--t-
'(signature)
District Number e/5 to A Place 7"a Wn 0 f O r L4_
e
tI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition cl 5 II$ Place of Disposition ___.___ , . . �t.. ®.-
'r�i I ( Pr s)
la
{sect+ar� oat number) J rave number)
Name of Sexton or Person in Charge of Premises h r ^ _ Uwttbr
2 (please pnnt
41 Signature _ 4__._.__, _..__.,,. Title _ filt-014 at
(over)
DOH-1555 (02/2004)