Detore, Nicholas .1 n'g
NEW YORK STATE DEPARTMENT OF HEALTH° A
Vital Records Section Burial - Transit Permit
Name First 1 ))\(._w) (oLs Middle Last _Oa Sex
frat e
Date of Death Age If Veteran of U.S. Armed Force
IC - Z Z--1 War or Dates i"�ick
E- Place of Death m Hospital, Institution or
W City, Town or Village QUQ Q -4�"' `i ' ' / Street Address a(.. Gd � S
0 Manner of Death ki Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
LEI Circumstances Investigation
W Medical Certifier Name Title p_
O ) Y1 SLOT
Address )Yt(4 �� p( a ,)il 1 c 1 y
Death Certificate Filed 1 District�riy Number Re ister Number
City, Town or Village %r s /\..S 00 y sic—I I O
❑Burial Date CemeteTy or Crematory
lb Ja3 la-U2
['Entombment Address �, �
Cremation L-( (.�--Cc e-Yvs b U)'1-f i As i?- `"(
Date Place Removed
z ❑r-I Removal and/or Held
..� and/or Address
Hold
O Date Point of
Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to � r VD_ Registratio umber
Name of Funeral Home L l / r a), I,,�Y O/ '
Address ��� a �' ; �J,S1,0 /�� /2 ye--(
Name of Funeral Firm Making Disposition or to W om
104 Remains are Shipped, If Other than Above
$ Address
Cr
LLf
"` Permission is hereby granted to dispose of the human remains described ab ve as indicated.
Date Issued (0 22,1wt c51 Registrar of Vital Statistics C^-- „% :
(signature)
District Number'cL M Place I C:: v--(-1 C ci
I certify that the remains of the decedent identified above were disposed of in accorda la ith this permit on:
til Date of Disposition /0 Place of Disposition
2 (address)
Ltd
iO
CC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises (iir.. Se«�W-
► (please pri t)
W Signature �! 4- Title ti/041TP'
(over)
DOH-1555 (02/2004)