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Sidusky,James Arthur _ a 7b6 NEW YORK STATE DEPARTMENT OF HEALTH Budat - Tnans t Permit WlmnodVfti Ra ords Name Nm Middle Ian xa dneenmm�eM ' Wkd CeaM1 >g I(VMrmaLISMrN9311 WFtIrzJM ]B Veem Wxar Doke 1�igM) % Taken FbspNl,lnsLunonor C ioxnarNl 4ke Gm iavm SireelAddress NwYmey,WHGeaq Twn, Nw Yak t}815 ManmrolDean � NanmlCause ®A«den ❑Nanaide ❑xlnx �undekrmimd �wneim urea lm MNiW@Mn Nane rnh canna Daad.n Cwaer Address I W 0 St Haub 9,Lake Gaoga Tvm,Naw Yak I IDe5 da NCeniliuuiikd IAmin Numna Peglskr Number ConjovenorVotlen, leb d�I k ❑Burial Dwm�%rFxilm Nane ❑Emomnmem Address pfamamn aN.a'awnTwe,NueYak ❑Dan.r ❑femoral Daft plxehnmM aadkr aMlor AM Had Address _ QTranspawdm wk Po'mA n nYfomnwn M' Lamer Deatrama ❑Divestment Due Rmem Alerts: EllReimement has Gun N was Purmisuedm Pegnmwn Numter Named Furtrallbne M rmrY Xare-FaI EM'aN mm8 Manus 82 Amway.Fon Edwad, New Yom 1M8 Name A Furerd Flan Making Disposnm am When Remains are Manxa4 If UAertlwn Abrt Address 6 W a Parmiselm Is NxeMY grafted bEiepoM of Me human anMna WmMM NMov u eE e lnENvbtl. Des Issued oenarzom Re®ium trAyulsatinira rAltnm RRMlB mn Slhmff 4m MIXYS'V" o-rwrmw "W "Im, sasl Net LakeSwge. 1s wYM emp Inm Ins remMne A Ins rtemwn iaNkred anoVe were diapo.a a m aaermme wim mi.pmnfi on: Dm ADkpaaaw /, Imlm puaa oMwiLtan E wa. w a awrw xr,mms.N rdam�«n Smaw ol5esmnahrwn in Clean Apremissy / awU Tim W signature DDX�asss lmhdl Pldz Nblic Health Law Sec. 4145(2b) 013958 Receipt Human remains of �t livered on �� • 7AzU I eNeview Cenaim Neprcxntingtla fiareNM nvro]on dmal pmmn Official F.gO gyms Reg.mu M—}}rfj