Guyette, Terrence NEW YORK STATE DEPARTMENT OF HEALTH ,� Burial - Transit PermitVital Records Section
Name First--� Middle Last ) Sex
l k'rr c,e 1- w Af -) ( )Lr((ie 1 M
Date of Death Age 1 if Vteran of U.S.Armed Force,
/O/2Lo// to 1 �Q 1 War or Dates A I4
of Death /� Clospital 'stituiion or GI-e-'s f-a.115 HoS�)i� 1
• Ci own or Village t,�` } Street Address
111L-• Manner of Deaths Natural Cause E Accident fl Homicide ❑Suicide Undetermined fl Pending
Ilt 1-1 Circumstances Investigation
ta• Medical Certifier Name ,�� 6TL 1<� ' �� Title
frl
Address
I fl u.._ "-is-- a t4-/us &Liz /by /Zeo
Death Certificate Filed L -,�, S ! District Number � � 'Re ter Number )
C Town or Village i
:::><❑Burial Date Cemetery or retnatory,
❑Entombment D kg' Co �i
Address a
1,�_n
__ CYemation l)If?/i-��- Y` OL f ayo
,,,„
Date Place Removed //
— Removal 1 and/or Held
—and/or Address
Hold
cri
0 { Date Point of
Transportation Shipment
by Common 1 Destination
Carrier
C Disinterment Date Cemetery Address
0 Reinterment Date I Cemetery Address
zS Permit Issued to i-� Registration Number
Name of Funeral Home L . hex �::;1L,'Z.L\ \- occ\t- C�•I 1 L
Address
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
M
w
Permission is hereby granted to dispose of the huma remain escribed<above�aas in• rated
Date Issued U�A CtlD �j?�Registrar of Vital Statistics iyy /j� / ' A -.
signature)
<= District Number ,,jr I Place CL-g6, >7
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
t Date of Disposition /0(3i hi, Place of Disposition -f iP.e 0.,, i i on,—
2 (address)
III
C (section) ( (lot number) (grave number)
0 Name of Sexton or Person in Charge of P emises /' t r ori
(pi ace print)
Signature Title k/MVP&
(over)
DOH-1555 (0212004)