Cusack, Evan Joseph +T--12Aa 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ma le
Date of Death Age If Veteran of U.S. rmed Forces,
(� _ ar or Dates
14 Place of Death os I, Institution o
City, Town or Village,, j1� ' Street Address >
Manner of Death Natural Cause Acc dent ❑Homicide ❑Suicide ❑Undetermined ❑ ending
�
LL[ Circumstances Investigation
Medical Certifier Name Title
' 4— 5. Vi C r l'L
Address
1 2
Death Certificate Filed 11istrict Number Re ister Num er
City, Town or Village
❑Burial Date Cemetery or Cremato
❑Entombment Add s 1 �
remation
Date Place Removed
❑Removal and/or Held
and/or Address
w" Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to t _ Registration Number
Name of Funeral Home �� n 1-
Address
. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem described ab ve as indicated
Date Issued Registrar of Vital Statistics .
(signature)
' District Number Place Z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3-/yZpzp Place of Disposition P-�
(address)
(section) (lot number) (grave number)
Name of Sexton or Pers in Charge Premises ��y/j10^1 J
(please pant)
Signature f Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 013435
Receipt
Human remains of delivered on , 20
Pine View enft'tery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#