Hendy, Jr. Harold 1 1 4 tiiL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , - Burial - Transit Permit
Name First , 1 Middle4 Last i 1 , Sex-14kral- Lk ne.,A,...0,
,...: Date of Death Age If Veteran of U.S. Armed Forces • ,
i;•::i 0I, 70 War or Dates
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i..:, Place of Death 7,-, Hospital, Institution or
CitycTor liege C-o r.•••AJCt- Street Address 1 ")r t:pt0 tr i-A no-
tMan er of Death a Natural Cause El Accident El Homicide 0 Suicide 7 lin/determined n Pending
, 'Circumstances 'Investigation
•t.4. Medical Certifier Name 1 Title
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...,. Address
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Death Certificate Filed .. District Number 1 Register Number
City, w ,
or Village 6.- r: n_,A0+- ---1 5-513 9
Date Cemetery or Crematoryfl
Burial 5-7X•b// A d, % ;,,,e-v:0-, d,,,,
Address
_Y.Cremation 62(..A.z.....e._A..‘›hc,.....r-1 -',
Date Place Removed
Z — Removal
and/or Held
- and/or
I-- Address
w o- H Id •
0 Date Point of
al —Transportation Shipment
-th- by Common Destination
Carrier
— Disinterment Date Cemetery Address.
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 7-e.-itc.,A4:)rc_ f,-4._,\er..},-• 1--L-<-, .1.,.,.._ O
0i Address
7 g er---,..-- Av-e-') Co,‘"-'-'4, , K1 1 /
Name of Funeral Firm Making Disposition or to Whom
t:t Remains are Shipped, If Other than Above
Address
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Permission Is hereby granted to dispose of the human r: - •:scribed/boy: •s-• •icated.
Date Issued CA-74 /' Registrar of Viral Statistics Age S 2-i 4
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lkil District Number Y 5 .0-3 Place 4_.. ..;..
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. ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition SIzlili Place of Disposition .e
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2 (address)
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cc (section) gqt number) (grave number)
° Name of Sexton or Person in Charge of Premises i IA It.. 3,-,.iiit
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et , -c" (please print)
LU Signature Title
DOH-1555 (10/89) p. 1 of 2 • VS•61