Szalai, Frank et Z9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name _..First Middle t Sex
-fi-r'�lC T��� a,` " ! �e-
Date of Death Age If Veteran of U.S. Armed Forces,
1 -0-3 -cD.p i(P %( War or Dates q m-x._e
Ih Place th Hospital, Institution o c(
4 Cit Town Village (,Le��5bLV i, Street Address -c Ckil-I2�
ci Mann r of Death IA Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined El Pending
IW Circumstances Investigation
flMedical Certifier Name2i ,, Tite S \v) ( I o
Address /L.- (-4)1C--e-e-0 b
Death •-
- ...te Filed '�� District Num er ' Register Nui
City, Town •'Village wW—i�CDi it( 5to I 1 D
❑Burls Date ___ /111 Ce ery or Cremator
Entombment id_ .-,7 -f i n� t co' LA) �`�J--b
Address
pCremationu_sc- 1 Date r PlaceGI)Rtk:e_e.,,,tc.101A-y-. 1/4?),--)
emoved
Removal and/or Held
-
..- and/or Address
— Hold
U)
0 Date Point of
dEl Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Regi
stration Number
Name of Funeral Home 1 cync4-e. t t,,-,.R-r. 6yi .� 60L1Lb '
mg Address l ` j
S�'l nAa.,,, 14✓e. u f. 7
Name of Funeral Firm Making Disposition or to W rti e Shom
I Remains are Shipped, If Other than Above
'; Address
lW
,' Permission is hereby granted to dispose of the human re ains descried above as indicated.
Date Issued (3- 1-t Registrar of Vital Statistics f-`--
< (signature)
District Number ��S Place 4,,,, i. � ,
r.
I certify that the remains of the decedent identified above were posed of in accordance wi thi permit on:
2
Date of Disposition /2/27// Place of Disposition hgU, e.44,) Cra yn6
(address)
LU
to
cc (section) / (lot number) (grave number)
Q Name of Sexton P n in harge of Premises Jt„ ,4 CJ 1)44Y4-7,.%tI`e
z (please print)
Signature Title C.(erne,/e✓
(over)
DOH-1555 (02/2004)