McCann, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name —€+�s� Middle Last Sex
- �t� t�C
IM off Death t A If Veteran of U.S. Arme F
-�i War or Dates
Place of Death Hospital, Institutiorl qr
City, Town or Villag Street Address
Manner of Death Natural Cause Ac de t El Homicide 0 Suicide El undetermined nding
Circumstances nvestigation
Medical Certifier ame Ti
Add s
Death Certificate Filed District Numlier� Register Number
City, Town or Villager
Date )CgWtery or Crematory
❑Burial 0-'cJh
remation A sU� [ Zc)a-C� r r
Date Place Removed
ZRemoval and/or Held
-- and/or Address
Hold
Q Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to R is ration Number
Name of Funeral Home
Address
LA
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W. Address
Permission is hereby granted to dispose of the human mains described above 7ind icated.
Date Issued egistrar of Vital Statistics l
(si natur
District Number— - Place ( � �►'
I certify that the remains of the decedent identified above were disposed of in accordance with his ermit on:
IN- ��� y�r / t
W Date of Disposition ' —�� Place of Disposition�/—f /� I�d �c✓ � .�����,& /1d&
(address)
UJI
(section) (lot numbed. (grave number)
Name of Sexton or Person in Charge of Premises
(please print) r
Signature ✓dt/Z2$__� Title >/ r
DOH-1555 (10/89) p. 1 of 2 VS-61