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Zayachek, John
3 6 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First --o�W Middle z� Last Sex� , J Date of Death Ag If Veteran of U.�d Forces, O 6--//-o26D(a P& War or Dates }- Place of Death Hospital, Institution or City, Town oVill 6 c -a nnot ((.� Street Address ___LIWairi /2/iQr Na/ ' 1�, 'rl ... Manner of Death -Natural Cause 0 Accident ❑Homicide Suicide Undetermined Pending W. Circumstances Investigation 1,11 Medical Certifier Nagle Title c ry i h /1 ra rice ek. �,t PA ,174 Address � /7d�s� lz Death Certificate Filed District Number Register Number City, Town o illays 6rt Wi`Ile 57a6' 75 ❑Burial Date i Cemetery or Crematory 1 DEntombment S _t� V(b1eV�ei,-) GeCA1�''lc'i-U�'um Iii AddresLwe t Y Cremation fY , V Date Place Removed Z Removal and/or Held 91 ❑and/or Address Hold ca 0 Date Point of EL ❑Transportation Shipment 0 by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to `��, Registration Number Name of Funeral Home /6Me(/ al fr4 ftt ru hQrat 7f##YYt L 0/3 73 Address "�J Nara( V !. 6r n i//r° /V/ /a1-4 30, Name of Funeral Firm Making Disposition or to Whom 1 . Remains are Shipped, If Other than Above 2 Address ff lei Permission is hereby granted to dispose of the human remains describ bove indicated. Date Issued O,/ /5 11(� Registrar of Vital Statistics ` ./r. � / (signature) District Number 5 7 5 Place I7::*e ©1 6reti G'r/4' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z ILI Date of Disposition c A-1/c Place of Disposition zin c v,:;� et y,,4 t 4';, ,,n,, a (address) to ul CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises C I, i'' ' C.I n sir z � �_ (please print) u Signature L-,' • ALA""�s' Title (' r'" (over) DOH-1555 (02/2004)