Jackson, Alma NEW YORK STATE DEPARTMENT OF HEALTH �_ �� I
Vital Records Section Burial - Transit Permit
s= Name First _.
�� Middle Sex
. lqLti4- r RC> d ( ,4Lr_--
f
Dake of Death Age f Veteran of.U.S.Armed Forces,
/4/d% Ue- C6 -
war or Dates
;` Place of Death
�r'� _�� Hospital, Institution or
#. City,ToNn,or V L Street Address 3 0-60-Afrotye 1 641 y
Manner of Death Eltiaturia Cause 0 Accident [�Homicide []She 0 Undetermined . :D Pending
r" Circumstances Investigation
, Medical Certifier Name Title
, �.tJ' �� 644 scams )
.s /r Number
Death ownCertificate C 31tber l•�C
�G City,Town or Village �1L �.gG3
Date
/ -/ 'r
Crematory
QEr tOR ement A C mn ry c}C co I y
Address 1 rt.' t '" 40( (-- 2-xk-Pc4'Lk--.. ' ad f y
Date Place Removed /
r 0 Removal and/or Held
I.L, for -Address
Hold
�� Date Point of
;`.QTransportation
Shipment
by Common Destination
41 Carrier
•
o Disinterment Date Cemetery Address
>• Q R Cemetery Address
v. Permit Issued to .�- Registration IWrmber
�.;:-
''v` Name of Funeral Home p..iJ L c �f-- ,f�� .1-iii C__ I / ��S'--
Address l fZZiF&.j
0.41,-EA. s rz--;9-e._c.s Ny ,011) /
,. Name of Funeral Remains are Shipped,
Making Disposition or to Whom
pped, If Other than Above
Address
pr Permission is hereby granted to dispose of the human ns described as indicated.
Date Issued 1(Ac 10IS Registrar of Vital Statistics` C-� 0 fu---„,
Y (signature)
V. District Number Q 4'''') Place 1 a Ls,.-+s. _G Ca L..,_Q k
I certify that the remains of the decedent identified above were disposed of in dance ' this permit on:
.`7,1 Date of Disposition to 1 9 Iii Place of Disposition L r
(address)
, •%•(section) number) (grave number)
.' Name of Sexton or Person in Charge of Premises tr 3 L+►4IPI
-1 r
._ Signature �`" 4" True fF v OA
(over)
•
DOH-1555(02/2004)