Zylberman, Kochawa r . 7. 17
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First� i Middle Last Sex—
A
Date of Death Age If Veteran lot U.S. Armed Forces,
5/.1,/ a,vl../ I War or Dates
F.- Place of Death Hospital, Institution or
Z itPTown or Village—ca S r'`, �- Street Address ,r H ;- -(
Danner of Death Natural use Ac ot d ent ❑Homicide El ❑Un termine ❑Pending
U � CT� Circumstanc s Investigation
ul Medical Certifier Name // Title
O K Grp"" Li to iJ
Address r ,�
_ r,„,_.}.." H• £-II,Ar y , �„�^.`-t id•/
Death Certificate Filed , District Number iegister Number
.:..,</diicDTown or Village ��t r� S. �u l
LBurial Date Cemetery or Crem
['Entombmentc/ 3-/ ' ,'n e v eta Cfc;r1,-11„
Address /f ((((((ffJffJ
Dire,atiOn ��L!"1L��_. Ale, / '/` ..
Date �J� Place Removed
• Removal and/or Held
2 and/or Address
N Hold
CO
O Date Point of
05 El Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to � Registration Number
Name of Funeral Ho
m G�s�� / v+�+r � ^"/ G° Y-`./
Address ,�
54e t•A,� Aire 6; (P. / 1< -z-
Name of Funeral Firm M ing Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
2
la
11
Permission is hereby granted to dispose of the human re ns c ed aIa tve.-sindicat d.
Date Issued 5/5- AlRegistrar of Vital Statistics "
(signature)
. District Number 9-co j Place S- ,1- 4 5 r , • 7
certify that the remains of the decedent identified above were dis� /U
ed of in accordance with this permit on:
LU Date of Disposition 5/spy Place of Disposition ' *� ,�a dr,fo.d
', ► (address)
L
CC
CC (section) (lot number) r (grave number)
CI Name of Sexton or Person - Charge of Pr mises t .mail
2 (p ase print)
Signature Title aZtiiihipt
(over)
DOH-1555 (02/2004)