McKeon, Mark NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
L
Middle st Sex Name First
/A
DaAt� of eat Age 3D lie ir If Veteran of U.S. Arm Forces,
l(00 War or Dates
Place of Death �- Hospital, Institution or
Town or Village : fti-,4C- Street Address df1 -s{� �'tT
t , T 9 0 Undetermined Pending
anner of Death ❑Natural Cause Accident Homicide Suicide Circumstances Investigation
Medical Certifier Nam r Title
rat f 0'e �.
Ad dre�� fV
_ District Number,_ Register Number
`> Death rtificate Filed L�vO
City, ow r Village
Date Ceme�ry,or Cre atory
LJ Burial //W010
Addres `A
WCremation u ie LN5 )-7
Date Place Rem ed
z Removal and/or Held
0❑and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
Date
Reinterment cemetery Address
/ Registration Number
Permit Issued toe-
Name of Funeral Home //�it� ,J• ✓�Gl��
Address �� RoaoW� �C�/1�t 5 (c,c� �d - AI
Name of Funeral Firm Making Disposition or tb Whom
^amains are Shipped, If Other than Above
Address
Permission is hereby granted to dispgse of the human remains described abovZs indicated.
Date Issued `� -�4 Registtrrarroofe i�Stafiics
(signature)
r Place yQo
s District Numbe
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Place of Disposition/ /
W. (address)
UJI
N (section) lot ukex) (grave number)
Cl-
GName of Sexto or Person in Charge of Premises (please print)
z Title
W. Signature
VS-61
DOH-1555 (10/89) P. 1 of 2