Hall, Vernon . Iva
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NEW YORKds Section tera :. pe�akn9
1{ at ar Dates
ec ,tai; lnst�tstton or O detetmrned s tn�esagat1On
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Vitai R A9e '':'.. o
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4 Un umstance
Name ! gtreet A:. Suicide Gera
eat � �� QHomticrde
Date of
D o� ent [itie
��� e Q Pc ,..
t" Place '
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a�ner of D
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- �t,er Number
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jied�cal Geri / tt�Ct A .......ss `- a ��.:
Ge 110 r Gtemato
..:::::::.
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peach Cert�f�cate : ..::::.
may,Towna
Date
..::.:::::
nBurial ( .....:..
Add ess Place R
emoyed
Crem
anon
andlor Neid
Date
0 ❑ Removal
r andlor Hold `Address ...
Point o
Date Shi ment
p..:::::.... P
N ( Transportation by
...:::..:.:
Common Carrier Destination
Cemetery Address
Date
Disinterment - ....
.:..... _ .....
Reinterment
Daie Cemetery Address
Registration Number
Permit issued to ,
Name of Funeral Firm ZLt r. .,,.:: .,..... ....
Address C`
a Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
_ .:....:::......:..:. . .... . ::::... .::::.: .::. . .
ata:
Address
M
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t 0 P6 9 6 Registrar of Vital Statistics_
(signature)
District Number c,"O S3 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Place of Disposition
2II (address)
to
cc (section) (lot number) (grave number)
pl Name of Sexton Person in hayg a of Premi s
w (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61