Sebesta, Ignatius I 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 1 1 • Middle Last S� e S'} Sex A
IgnatsuS A _ �_\
Date of Death Age If Veteran of U.S. Armed Forces,
2 I►2 � 2O 1 S -- War or Dates ) ci L1 g - f 95)
1 Place o eath Hospital, Institution or
City Town r Village pr rc I2 Street Address
Manne o Death®Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined El❑Pending
W. Circumstances Investigation
Ili Medical Certifier Name Title
Ca-, )- fbo\ Pip
Address
9 -4.- )-.G-k- Za,le- (-10 f)(-? -4.__ )-)\-/ 1 VZ6
Death ificate Filed District Number Register Number
'` City, ow br Village (�c‘_,)`-2
M:❑Burial Date 2\ti3 Cemetery or Crematory rl
2c��S ?‘‘ r-ev\QL.) L_ (cArnQl-ori
❑Entombment Addrest
iiiiil Cremation Q uee.c S\- u , KY--1
Date Place Removed
❑Removal and/or Held
and/or Address
LI Hold
CA
Date Point of
t: ❑Transportation Shipment
G'sE
by Common Destination
Ng Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Ig Permit Issued to Registration Number
iiiW Name of Funeral Home MC) \< , \mes FLAre \--)-0re_
opil Address Z (3 ro i For Jr-- C jc rJ i•-)1 I LS LE'
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
II
iti
1. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )) 1.- 1 l y Registrar of Vital Statistics ck j2311114 J?PA 1 r .
(signature)
41 District Number 5150 Place AYc
f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iii Date of Disposition?-41SL,20 i$ Place of Disposition Pine✓ V,.(,w C fe,ryi c(y
(address)
Lu
t/
cc (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises J cirri.ri..t, Ste/vs;f Z s
g "(please print)
Signature,, ✓ 42. Title C rt.,l k r
(over)
DOH-1555 (02/2004)