Smith, Dylan NEW YORK STATE DEPARTMENT OF HEALTH -' ill
A SSZ
Vital Records Section Burial - Transit Permit
Name First Middle Last .Sex
D /Qn Jay s�,/ �- Mare.
Date of Dea Ages If Veteran of U.S. Armed Forces,
I 0--
7 16 -Z 0 r$ c� War or Dates kip
Place of Death Hospital, Institution or n
W City, Town or Village C 6�ne C�"Q( Street Address 1(2 -2 Ch !. �L/( P'�cl
Manner of Death Natural Cause 0 Acdent 0 Homicide ❑Suicide ❑ Undetermined Pending
Circumstances Investigation
W Medical Certifier R i Name Title
0 ►motIrJ P1 a k i r ;(0,1 E .
dre7 -4o Jr
a
Death Certificate File District Numb Register� j Register ber�
N. City, Town or VillageoC he . eL'� ''7 li0/ o 2
: ❑Burial Date s� C etery or rematory
❑Entombment Jo I c�c 3 �� C I i ne' ' I L(O� C 14\a�71/17)
Address 0
Cremation C/�s2—� 4 S b U
W�i Date ce Remove
Removal and/or Held
and/or Address
l= Hold
10
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
PermitN. ameIssued to t 1 tur1QXC�i r i — Registration9umber
Name of Funeral//�� Home � �'
Address U13 -7 ii-ke. 30 / fl c) i a n I c /z Z.
Name of Funeral Firm Making P Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
L
W
Permission is hereby granted to dispose of the human rem in escri ed ab v/�aas i d ted.
Date Issued )Q ITC' 01 Registrar of Vital tatistics tt gna l k l Oh'
� , (signature)
District Number quo/ Place ,weeit r-t
iH I certify that the remains of the decedent identified above were dispos d of in accordance with this permit on:
WDate of Disposition /0 kit lit Place of Disposition fkq„+.,, efti'tof -
ag (address)
W
CC (section) (lot nuber) r (grave number)
p Name of Sexton or Person in Charge of Premises 6 d ry+ f /A Air
+�► (please pri )
tiilainitig-
Signature ✓l.c.-. Title
(over)
DOH-1555 (02/2004)