De Zalia, Horace NEWYORKSTATEDEPARTMENTOFHEALTH R . Burial - Transit Permit
Vital Records Section
Name Fir Middle Sex
mi D e of Death Age If Veteran'of-U.S.Armed Forces,
'�) �i p//f g$ War or Dates /l10
9
Place eath Hospital Institution or
W City Town r Village 13o -Th )wdso 1t) Street Address �aS N PO�d. a
.::Manner of Death ;-.: ... . :..: Undetermined� Pending
��' Natural Cause ❑ Accident ❑ Homicide ❑ Suicide
Circumstances Investigation
WMedical Certifier Name Title
o .......A. eel G ; 11N, r
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Addres [J / /
iM /d9, Y�d"4 ST• Pr-vp. P t�fns:./:....6 i_pNS..:fell� aAJ7..... I 9 0L:...::. ....... ........
Deat ificate Filed i District Number Register Mumber
City Town_Or Village /U� 1 v I CbJ /�-/ / 1- 3
Date nn eteryy pr Crematory
❑Burial d/ d-o 1 i' e U/ ::._E Alv.J'',}1
remation Address /
e-e Ns.1U
Imo.
z Date Place Re oved
O [] Removal and/or Held
F and/or Hold .::..
Address
a Date Point of
v) ❑Transportation by Shipment
Cr' Common Carrier .:::. ..... ..
Destination
❑ Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to �� / f ) ,�I Registration Number
Name of Funer • Ed A)l�YCL CMG%y UN21� ! /`' ` .S I 7,::
Address r
O
t- Name of Funeral Firm Making Disposition or to Whom
is Remains are Shipped, If Other than Above
u]>
it __
iN Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued 0/'--V-del/ Registrar of Vital Statistics '/''��r.�
/(signature)
District Number / Place 1J6..()tll K14,f 1. -- lam'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition 7/37/7 Place of Disposition ?PI QV (1 r& 4.-h q
2 / (address)
Ill''
0'
fr (section) (lot number) (grave number)
O ii
p'< Name of Sexton or P ge of Premises " !" -vl 4.Ie1�at�
Z> (please print) /
w Signature Title 6-leh'�,�ri,,
DOH-1555 (10/89) p. 1 of 2 VS-61