Grishkot Jr., Walter NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ei Name First 1 ‘ Middle Last Sex
P27-6vL 6j rGtu Ig/`1 ILA S/4-16) r J z M, 1--
-< Date of Death Age If Veteran of U.S.Armed Forces,
- Si/ /// P.�yr�S - Dates c dd (.)SCZ.
P e of Death ! • r, tthttiori or
C- , own or Village gc U^,4 C F iu i �� M ddress c/U,.),� F026 S
ner of D'eNatural Cause ❑Accident Q Homicide -Q Suicide El Undetermined []Pending
Ii Circumstances Investigation
in Medical Certifier Name Title
l
Address
D.- Certificate Filed z ��� District Number 51001 I Register j bier
:`> City,T• or Village �-k c�`,,i-s /`— -� N '�`
:s P Burial Date (Cem Cre tory 1 ('
■ t
Address � Y
❑Cremation - 67CG�� lc ai424.✓S fj /2 3
ti Date - Place Removed '
Removal and/or Held
ina H old Address
Q
Date Point of
is Transportation I Shipment
by Common Destination
• _ gi Carrier
'''` Date Cemetery Address
in Q Disinterment
l �Reinterment Date Cemetery Address
Permit Issued to Registration Number
gig Name of Funeral Home MO,/nar d-b-exkker ?caner ctl W(r' - Oil L - .
Address 111-(404-yQ.fie- SA-. , atiee )Sou ry , Ni e v...:1 `Alf-k_ 12 sd o y
Name of Funeral Firm Making Disposition or to Whom
ii Remains are Shipped, If Other than Above
Address
6
Permission is herebygranted to dispose of the human remains desc ri ve in.4 1,...
`> Date Issued S / 2-0// Registrar of Vital Statistics e4 -
(fie)
``? District Number J�6/ Place -/4it,o / l/r /L�'
iM-
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1 Date of Disposition Place at Disposition Pine View Cemetery
( )
0.1
Erie 81B 1
(seclwon) Pot number) (grave number)
Name of Sexton or P Charge of Premises Michael Genier
2 (please piing
Signatur y� .12A...LA _ Title Superintendent
(over)
DOH-1555 (02/2004)