Darrah, Melvin NEW YORK STATE DEPARTMENT OF HEALTH , r # 41
Vital Records Section Burial - Transit Per it
Name First �/1��jl 0 Middle c-NLast N Sex (VL
.� Date of Death�, �/ J
Age If Veteran of U.S, Armed Forces,
fpi $ZC Is- -1,0 War or Dates
Place of eath Hospital, Institution or t
+j City, ow 'or Village f I 1.valiti Street Address 3i� `� `�
Manne of Death atural Cause Accident 0 Homicide �Suicide Undetermined Pending
iiEE Circumstances '—' Investigation
al Medical Certifier .44 � vm ��#JOt A 73
to-
/ ddress
/ v 00 Pi?, 1-1e141-`ri--1 L"F 11- &t,uC r
N /
Death Certificate Filed h i District Number Register umber
City, own r Village ,,de04i3 / 559 Li- eqo/g/ a
i€❑Burial Date Cem o CCre atory it
�j Y
j1 1 R'I e �_rvNt rZ� r
❑Entombment y
Address /�' > f�
iiiii Cremation -al v ; �. ue)A-'r 513 i A L 7
Date Place Removed
Removal _ and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
C by Common Destination
lit Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
mikWi Permit Issued to L y Registration Number
.ef?I�t1�RR-r)
Name of Funeral Home . irur9 �''V t -i. Po pie QO S I'
ii Address t� L A '\/ V27D
lea * �o�rf 9 �CH Rvo,� rFc ,` Iv
ilin Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Permission is hereby granted to dispose of the human remains describe ov s indicated.
Date Issued -Zp_ If Registrar of Vital Statistics c�
Cl si nature
District Number &-9 Place Akewee,14412, /4 i . ) r
.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 311tllg Place of Disposition t,�V,,,, 4---
(address)
ja
(section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premises IA,A
"; (pl ase print)
Signature /-� Title fb2mgf L.
. (over)
. DOH-1555 (02/2004)