Brassart, Joseph it p
NEW YORK STATE DEPARTMENT OF HEALTH f- g
Vital Records Section Burial - Transit Permit
€< Name First Middle Last Sex
3 0S � -E. 1.- o..Ssaf -I— N.\
Date of Death A e If Veteran of U.S. Armed Forces,
I c� - oZ�- 1 OIL rj War or Dates
Place ath ) Hospital, Institution or ,/ /�
Z Cit , Town r Village Let Kam- Li..-z.�r't - Street Address /S7`1 f IJ io/ R-1` -t
Ma of Death❑Natural Cause N Accident Homicide Suicide Undetermined PeG�fding
Circumstances Investigation
Medical Certifier Name Title
el tiVe-kz\ LL 5' 1 tic M1-21
Address
cu &':Zd::: SI Lim -g d, Ni + a) “
Death ,-- icate Filed district Number -�5 Register Number
'I Cit , own . Village LA✓e Lt.-:..e_rl..... 33
Date Cemetery or C matory
❑Burial rca 73 i / apt� � � ^�V'i t..4...1 ��"'�`t'°7 Address !
®Cremation �t�S LA.!
,tits..) I c'(
Date Place Removed
2 ❑Removal and/or Held
and/or Address
aHold
0 Date Point of
NQ Transportation _ Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home OGA.1e..›rc &Ae_t4 L k-.-, J.k, ("e`f't'r(
Address
7 gc,-....4_,„ Ave Cyr 0r r Cg as •
': Name of Funeral Firm Making Disposition or to Whom
e Remains are Shipped, If Other than Above
im Address
CC
iiiii Permission is hereby granted to dispose of the human re 'ns desc 'bed ab ve as indicated.
ss'; Date Issued ito/g,�d/"Registrar of Vital Statistics `
j (5 nature)
<>= District Number Place , ,iv y�e
0
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
W Date of Disposition 10 /3l/li Place of Disposition 4.1 s
2 (address)
Cl)
>l (section) J// (lot numb ) (grave number)
0 Name of Sexton or Person in Charge of Premises ib ;,y4„ o ,�1
z
L (please print)
U: Signature / Title mt41Vf
DOH-1555 (10/89) p. 1 of 2 VS-61