Loading...
Brackett, Steven elf 133 q NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Per it Name Fi t '\ Middle Last Spec 7-' " tI t ) ' 'tier R >�c1�t5T7- /7,O2,t' Date of Deat0 Age If Veteran of S.Armed rces, Y I 2,2 /2 `/ i - or Dates /ti/i`1- -ce of Death , Hos." - own or Village,K)1 Z.i -To t treet Address 6 G /9 UI ct anner of Death Natural Cause El Accident El Homicide Q Suicide �Undetermined Pending 113 Circumstances Investigation ta ul Medical Certifier Name Title AL PALti s°$ P1-0.014111 p Address CZ l p �,,p S e itr/xS �N r 19 5 Il F-rT�G�q' i4t ath Certificate Filed District Number L1501 Register Number [[Cit own or Village S0-y'Z C A- `<'>El Burial Date l Cemetery 6Cremato ..5 +/// /) LA)tc LlE-1-1) im ❑Entombment Address Rd2fcremation U t9'ie_6 g-0 , J 6%t•'S(S' , A Date Place Removed L ❑Removal and/or Held / and/or Address t. Hold Date Point of o Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address i!iai El. Q Reinterment Date Cemetery Address ii Permit Issued to Registration Number Name of Funeral Home to,/noJ c , k r Euner cal &rr 0 l 130 Address 11 La .yQ"He- S-• , QU_eenS ry , Niece 'York_ 12s'oL • Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address re - Permission is h r by granted to dispose of the human remai Avb.,, -ndicate Date Issued 5 1 '2©1 �- Registrar of Vital Statistics (signature) District Number 5O1 Place \ Q_,('cL' S p r1 "' I certify that the remains of the decedent identified above were disposed of in accordance4 with this permit on: 2 tit Date of Disposition 5 jtj f7 Place of Disposition �,4/110. ot,.., (address) L i rE (section) / (lot number) (grave number) ti Name of Sexton or Person in Charge of remises /ir r SBaq'it ( lease print) • Signature �` dl Title CREIvil AL (over) DOH-1555 (02/2004)