Cuzzacrea, Stephen { , 4gfl
NEW YORK STATE DEPARTMENT OF HEALTH /�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
STe Ae.4) 0 - " et, ctc,rea., Maka_,
Date of Death Age If Veteran of U.S.Armed Forces,
//— 8-e - /9 ✓7 c War or Dates / 76 7 — / 76—
IH Place o •-ath - Hsspital, Institution or
Z City, gown •r Village M.' ' Al 2.rc/A Street Address / '7'? A--04 e erp id uc'A) ec'
0 Manner of Death '��`i atural Cause El Accident El Homicide El Suicide ❑Undetermined ❑Pending
U4 Circumstances Investigation
la Medical Certifier , Name Title
Address
f 6 l i'A r/L-- 5 r-re.,2.1— 6 I.p ' -1‘t Is AL), - (i40 1
Death -•.ficate Filed District Number Register Number
City,' own • Village 03/'A)erV /5 .s'-'7
❑Burial Date /� CCetery or Crematory �-�-
['Entombment clid 2 0 // L i&L di 0-40 e r -'n tiv r y
Address
i. [Cremation v€-Q /jvy
Date Place Rem ed
❑Removal and/or Held
..� and/or Address
W Hold
to
0 Date Point of
CI ri
In Li Transportation Shipment
ci by Common Destination
Carrier
El Disinterment Date Cemetery Address
's❑Reinterment Date Cemetery Address
: Permit Issued to �r Registration Number
Name of Funeral Home�tvq r A , /A rr,w era / N0 re.e- t�t'S,s 17
Addre� e L. A./� yl.)--y. ', / )--e 71
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
cr
t
Permission is hereby granted to dispose of the human mains described above as indicated.
Date Issued Wag gyp/7 Registrar of Vital Statistics ._, Q--l`-1,—
(signature)
District Number f 4y''7 Place 1,/J f N k,u A ( X.
I certify that the remains of the decedent identified `above were disposed of in accordance with this permit on:
Ul Date of Disposition 1/i Z 1 I n Place of Disposition @'iuk ..-1 (ems f o r�
(address)
Ili
iz (section) J//� (lot number) (grave number)
Name of Sexton or Person in Charge of Premjses G kr,, 3'^"'it
2 d (pl se print)
„„„„„, Signature �� Title alb 11/1 r''t
(over)
DOH-1555 (02/2004)