Arsenault, Jeffrey NEW YORK STATE DEPARTMENT'OF HEALTH 3/
Vital Records Section Burial - Transit Permit
Name First - Middle Last Sex
.e.-t-t rf 1 11 r ncz ii Ma 1�.
<= Date of Death Age If Veteran of U.S. Armed Forces,
11 ON- i/.. f 7 5 War or Dates !'
. ) Place • Death Hospital, Institution or / ^
City, Town •r Village j�c i(,i,n Lai--- Street Address 1 3j q ti) ,� 73l ILL l LC I
ut
Manner of Death EA Natural Cause El Accident 0 Homicide 0 Suicide riUndetermined El Pending
i Circumstances investigation
ta Medical Certifier me 1 1( V) b, pr`qJ KV4i C
• Address ,
1 nA l (gin LO. 1/
Death Certificate File ^ District t pt Register Number
giiii City o , or Village 1 ry i ,- vi i/ '
Burial Date �mete�pr Cr matory
?' Entombment �os- l i - l _ I-l r)C V i e 1, r IYi /c r
Addr� I,� J
Cremation `�l l CCc f)5bl ka j
Date ' Place Removed
❑Removal and/or Held
and/or Address
ho Hold
Date Point of
al 0 Transportation Shipment
.
f by Common Destination
Carrier
if Q Disinterment Date Cemetery Address
Q.Reinterment Date Cemetery Address
iiiiiiii! Permit Issued to ii Registration Number
Name of Funeral Home �'1 I 1� � -Z.L �J,�-�� � '�'y Q I r y .
>`> Address 6 7 l yr S i�±.F \..J6 l i(Cr-i 1 i a1(. A,'� //q--2
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
`` Permission is hereby granted to dispose of the human m ins descri ed above as indicated.
Date Issued Registrar of Vital Statistics i "
(signature)
'`>3 District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k;;;.,.:
tU Date of Disposition /1 I T J 1") Place of Disposition �„4 4 � �-
(address)
Ili
ta
Cr (section) (I t number) d, (grave number)
ta Name of Sexton or Person in Charge of Pr mises Si•-•vi `�
! /�� (pleas print)
Signature f/� Title P6 ��
9
(over)
DOH-1555 (02/2004)