Starzec, Matthew NEW YORK STATE DEPARTMENT OF HEALTH .
Burial - Transit Permit
Vital Records Section
47:47-71r-rna First • Middle „J. La.st j4,14.4.
Date of Death ,', Age if Veteran of U.S.-XrZ1 Forces,
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rice of ii-'..-- ' -..-
City,Town or Village
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' Manner of Death I
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/ . Hospital, Institution'Orit i'-' '
11.? . ' Street Address
I 4- Undeta ined ri Pending
Natural Cau El Ac Went ii Homicide El Suicide 12 . '.. . .. . .. . 7.--
Circumstances"' Investigation
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Address
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ki-beath Certifiiled -,4 DistiiCt Nurnber ! Register Number
it4 City,Town or Village .,:, ) .
Date" i ems Or Crepty‘
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. 0 Burial - / TgO -:' r.L.4(...L, . . .., . .
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Address ""
:t.: ; Date ; PI Removed
0:0 Removal i i an or Held
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.1...: and/or Hold *Addrea
Date
Point of " "
A 0 Transportation by Shipment
#. Common Carrier -Destination— '
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• isinterment Date i Cemetery Address
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Data : Cemetery Address
0 Reinterment
in Permit Issued to 3teAte}i.. .. ., , tie. 1 Ftegistration/Number
Name of Funeral Firm
Address ---
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Name of Funeral Firm Making Disposition or to Whom
la Remains are Shipped, If Other than Above
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Permission is hereby granted to dispose of the human r-. •! :',74cribLe , .ov: 7 'Witted.
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4 Date Issued 8 /6 93 Registrar of Vital Statistics
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I certify that the rem Ins of the decedent identified above Were disposed of in accordance with this permit on:
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Z Date of Disposition - - Place of Disposition/ /MA-
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ESi (address)
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TC: (section) (lot number) (grave number)
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Name of Sexton o Person in arge of Premi s 472 4.)/9/ei) Ar97---iFylii
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. Signature Title ‘73797
DOM-1555 (10/89) p. 1 of 2 VS-61