McCormick, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
b lV 1 • c. L
Date of Death + Age If Veteran of U.S. Armed Forces,
c War or Dates
e of Death Hospital, Institution or
City own or Village LtvS Fii¢1L j Street Address L�,a� ,, L
anner of Death Natural Cause Accident ❑Homicide Suicide EjUndetermined I Pending
411
Circumstances Investigation
Medical Certifier Name Title
_ � �•
I D
Address
Deatb Certificate Filed � / District Number Register Number
own or Village Lfy5 r%1L(�.SjpQ r ,
Date 7 for Crematory
Address
Cremation �{l.�u /� '/L Cf,�� �t1 �, 15'i�q .-n . J�
Date I Place Renfoved
0 ❑Removal and/or Held
-- and/or Address
>
Hold
Q Date Point of
Z.N ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registratign N tuber
Name of Funeral Home q, L21
Address
L �-� ;
Name of Funeral Firm Makind Disposition or to Whom
IVRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hLrnan remains ddd�oscribed abo-e as s^ated.
Date Issued 1 Registrar of Vital Statistics
(signature)
District Number Placef 1,yLl,5, Al
I certify that the remains
�ofgthe decedent identified above were disposed of in accordance
nwith this permit on:
Date of Disposition ' `9O Place of Disposition //��� � G�i�/►1�/r
(address)
i� (s tion) � (lot n be n ) (grave number)
0Name of Sexto or Perso in Charge of Premises ,�C.J ,� /✓��[ /7'CcJ
(please print) C +
LU Signature Title �i J/
(over)
DOH-1555 (9/98)