French, Dennis e :,,. �5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First , Middle Last Sgx
Date of eath Age ) If Veteran of U.S. Armed Forces,
—3 w ( S (D Z- War or Dates Y\ 0
.H Place of Death Hospital, Institution or
. City, Town or Village Son Fa 5 Street Address I C1 Ma ( h Sf A t" J
oManner of Death Natural Cause O Accident O Homicide El Suicide O Undetermined O ending
W Circumstances Investigation
w Medical Certifier N me //�� � Title
4 Kobe ', ,& IC (AA Cc�rov1.Q r
Address
[41A01 s on \\5
Death Certificate Filed District Number Register Number
City, Town or Village S p r1-'\,S _T-7..z 6 06
OBurial Dated Cetery or Cremator
❑Entombment `J � 1 ' V ( CAA)
tl\-)
Address
NCremation G GIQ Z..1A5 bi ,(L
Date Place emoved
Z Removal and/or Held
R❑and/or Address�
Hold
0 Date Point of
95 Transportation Shipment
0 by Common Destination
Carrier
[�Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Home-br){"r -A.AtQ l k n.'- 1 yl - ODD-1 1
Address
)4-- Qii‘kki-ci-, St tato_ LIk2-e-riu, SI\( (Z_S 4-6
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
#X
IL
'` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued . "`-.Oc- Registrar of Vital Statistics Ci\,
`�8 (signature)
gqiq District Number-7 Place at` 1" F-co_j>
I certify that the remains of the decedent identified above Ire disposed of in accordance with this permit on:
p
LU Date of Disposition 3 i b hi. Place of Disposition k sL, (n
,i '"-_
a (address)
Ili
CO
CC (section) A(lot number) (grave number)
• Name of Sexton or Person in Charge of Premises ` ��+ —" 41+
14 (p a se print)
Signature �l�-'� Title ( olft WU
(over)
DOH-1555 (02/2004)