Banon, Walter 11 I
NEW YORK STATE DEPARTMENT OF HEALTH r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death + Age .If Veteran of U.S. Armgd Forces,
Jib 1 P 3 War or Dates ,„,)J19.-
iil
Place • Death Hos -tali Institution or
Z City,g ow r Village )1,g,-�, -,=a Street Address.% f az C,c.e,t i-J�u ✓.r .
tliManner of Death 2 Natural Cause El Accident El Homicide D Suicide El Undetermined El Pending
Circumstances Investigation
ill Medical Certifier Name Title
{,� p
ifrac tip
Address r'
Il) C- ram. Q o f d krill A7 (770.
Death - ificate Filed District Number A 'Register Number IL
City, ' own •r Village 4L r o rwj 1
CI Burial Date Cemetey or6emat
['Entombment Address
/Zi)B " .mac- U/b�
Address
ii!!Ili BCremation Q J,tlk ,.. fj Q Oce-ni f Q 6 ,Ajy
Date Place Rem ved /
❑
Removal and/or Held
▪ and/or Hold Address
in
O Date Point of
lik D Transportation Shipment
C by Common Destination
Carrier
ii
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Ho.,/nut d -0. 6eLker Rifler cal f-to(w_ 0 t ii Et
Address 11 LanyQ-i-1e S, , Qk. .eens\owv , N.ev...3 N/U� 12?OVA
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
til
ll'`•
Permission is h reb granted to dispose of the human remai s escri ed�a v s indicated.
aDate Issued i ( 0 Registrar of Vital Statistics ,1,4,A, WC
(signature)
District Number j�SC\ Place 1'�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
`l
n/1
tLl Date of Disposition f,/5114 Place of Disposition EAIR.r (cw t o ram,
(address)
W
t
Q (section) / lot number) (grave number)
C] Name of Sexton or Person in Charge of Premi es /( 5.N•,f
2
6 (pl ase print)
Signature Title (*AI
DOH-1555 (02/2004)