Breault, Bradley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex `A
Brad\C-y A\\er, e,ceaa\ a- I 1
Date of Death Age If Veteran of U.S.Armed Forces, .
ail a g I at y l0 9 War or Dates V i C-3-r a M
Death Hospital, Institution orri5rof
own or Village (3\QY\S FA\\S Street Address G I Dh S qk\\s OW;+a i
Manner of Death r Natural Cause 0 Accident L=I Homicide Q Suicide riUndetermined El Pending
tit
Circumstances Investigation
tu Medical Certifier Name Title
A Je_IV;.c S 1-0b•n M
Address
\ L\ Munoz k)(- C?k %tir7 , Al)' ).2.W4
D--th Certificate Filed District Numbe Register vrpber
awn or Village C1�r\S 'a\\S (OQ/ n �j
Date Cemetery or Crematory
1:/Burial 2
:iE['Entombment03) 05 j aoi ti P i n e V t e'o Come ry
Address
'« ['Cremation Q u.l.V\D Q o&c\ CI'vAtev\S ui"-, t;I
. r2.-�'
Date Place Removed
O Removal and/or Held
and/or Address
Hold
Date Point of
O Transportation Shipment
by Common Destination
Carrier
Iii.ID Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
i!IV Name of Funeral Home 14ayna 8�, 60,1er FuneroJ ' ( 4 0( 130
- r-Address w yv r ML 12 U
It La ye.-fie- S. , C�t-Lee.r,S fv
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
LA
i:> Permission is hereb granted to dispose of the huma remains escribe 'above as indi ted.
Date Issued O 0- chi 0 i Registrar of Vital Statistics Cf�i(�r�\�-�
�� (si nature)
District Number C Place C;c
I certify that the remains of the decedent identified above were disposed of in accordance wit is permit on:
3/5/14 Pine View Cemetery
Date of Disposition Place of Disposition
2 (address)
iii
Mohican 30 D 1
C (section) (lot number) (grave number)
Name of Se.i on or Person in Charge of Premises Connie L. Goedert
2. (please print)
': 142i Title Superintendent
»: Signatur-
(over)
DOH-1555 (02/2004)