DeMarco, Steve • 6:% 6-
NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records Section Burial - Transit Permit
or Name First ,...
Middle.-- . . ',,, Lap); Sex
Lc
tcl-
iiigi Date of Death Age . If Veteran of U.S. Armed Forces,
..,....
11-J se c_ a }3 D..00 6 1
/ 7 War or Dates I 1 5-0 - S-L1
111' P - - of Death Hospital, Institution or i,_
own or Village^ - 6./e..-r-, --1-10-,._ Street Address t-A e.-.‘ Pa^K. ki 04.1("I"6tt 6---- -
§ 1 -nner of Death= Na ural Cause 0 Accident 0 Homicide 0 Suicide 7 Undetermined 7 Pending •
1—ICircumstances ' Investigation
...
Medical Certifier Name') , Titi
/ ,_
Address
11;11 1 7-) L.-) ck/'f,- >' i 6lt,, ._ .77. J Ni ) g 0 /
11 WI'Certificate Filed District Number Register Number
CCrown or Village ,),F 6Le,N5 F,ity- s- 0 i_ 6, 5 S—
...
Date Cemetery or Crematory D
. :::, [1:1 Burial 1'). fkilioQz / i/lev;c-/ 6e , —
Address
Y Cremation
Date
Place Removed
2 =Removal
0 L-1 and/or Held
and/or Address
Fi Hold
Z:) Date Point of
rjj 0 Transportation • Shipment
za. by Common Destination
Carrier -.4.
Disinterment Date CemeteryCemeteryAddress
1:1:1 0
0 Reinterment Date Cemetery Address
1111i1111 Permit Issued to Registration Number
Name o f Funeral Home ,<-
1E1' 0-- -Yv14 i
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ter
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Address
11i1 7 SrlAe ,0•-, "' K72)r• P r 1.), tt-1,2_
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, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
sr0.
IL
P;
F. Permission is hereby granted to dispose of the human remains described above as in at
111.1111' D• ate Issued 1 Al /0 6 Registrar of Vital Statistics ,
(signature)
....,..:
.....
.....
1111 D• istrict Number 0--- o/ Place 6r , .utr :.lz- E,L-d2 / ‘1. .,•_ 107 Air
...
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.I .,
EDate of Disposition 1 /4:(1 A C Place of Disposition -1210.k.v u..., Cre-ft-4.t.c.,r IQ vii--
2 (address)
ill
U)
CC ' (section) 7)/ (lot number) (grave number)
° Name of Sexton or Person in Charge of Premises ( In It
.0 Z ';?i (please print)
PO Signature 1 41N, 41).Ava— Title C 1-tin L.-Ft.,r-
(over)
DOH-1555 (9/98)