Curl, David I 1 ��
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section - Transit Permit
Name First Middle Last Sex
DoVtcl MAgecoef, Ct� r) � l�
Date of Death If Veteran o U.S. Armed Forces,
10—Lc' -2O1 8 War or Dates !q-) l—1 q 73
fi4 Place of Death Hospital, Institutio gr gasp
5 City, Town or Village C LDS Fa/r/3 Street Address (71ff/1 S //5 gasp)u. 1
faMannerof Death Natural Cause Accident Homicide 0 Suicide Undetermined Pending
U Circumstances Investigation
Medical Certifier Name Title
0 ehrls- l ,r- 14-0\i Mi
/^\ Address
L-G[uze.. 3 burj e
vy
th Certificate Filed,..-, )�p,,,_� ./ District Number Register Number
own or Village t.C.0 1 3 / /S 500/ y 7'
❑Burial Date Aemetery r Crenvtory
Entombment '0/4 / g /11 C ` ' el-0 -Je-�`Ytx-YL�
Address /
Cremation IA-e 15foam)
Date PI ce Removed
Z Removal and/or Held
2❑and/or Address
t. Hold
tO
0 Date Point of
ti Q Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to r ,, Registration st� Number
Name of Funeral Home jr�; '-, i'1.,„"),C. -r HO A.(
Address a lL h a `-h St f [2.$440
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tC
-
Permission is hereby granted to dispose of the human remains"�-�described above as indicated.
Date Issued (0--(j L,\J tots Registrar of Vital Statistics C XVN 2 W-
7A^j'6
(signature)
District Number 5(00 l Place ri 4.y or 67,6 s11[,
i„ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IILI g Date of Disposition to 1(fl its Place of Disposition �L 441tr ►�.
(address)
Ui
LC (section) (l numbier) (grave number)
C.
Name of Sexton or Person in Charge of Pre ises tAripipillor £.*
(pleas print)
lf! Signature Title 6 iliA`(
(over)
DOH-1555 (02/2004)