Zuma, Michael NEW YORK STATE DEPARTMENT OF HEALTH Burial ® T�°aI'tsIt Permit
Vital Records Section
Name First�,�is J .viol .0 k -24.cywo,
LastSex ;fin
l- Date of Death A e `J If eteran of U.S. Armed Forces, /i' +
F �1i 2d i g+D 1
-�<� War or Dates
t ` Place ....0eath �.y i nstitution
. ,la
City, or Village `�` S 4M Street Addr 1 04 r p(5Hw 0 Q1 b f i _
�� Manner of Death a Natural Cause n Acciden 1-1 Homicide1-1 Suiciden �
Undetermined Pending
a.
Circumstances Investigation
Lta Medical Certifier Name fast ‘At6A Title t Y lb
Crff FY1
Address Q f t ,S f• cis T, ;1 S N it v Ir l Z�O I
Death C-rtificate Filed' D is Nu ber Re ister�Number
City, own or Village S btu,.
.00
c s C Burial ( Date Li ri_ I t 4, Cemel.ery . Cremato
❑Entombment Address ) t Y V
Cremation Date Q W " • (1U-k-EA'6' kt-Nti yo I r
1 and/or Removal Pla/e Removed
® and/or Held
Address
tt£a_
Hold
Date Point of
co Transportation C p Shipment
by Common Destination
Carrier
Li Disinterment Date Cemetery Address
Reinterment j Date Cemetery Address
Permit Issued to - 1 Registration Number
Name of Funeral Home PY`,�Ze ' T. ;Zk\ 1-jQ -N- C12-.4 t `}0
Address
kk Lc a..1 - 4- C;k3t ,ems\ L-,- 1 , \! 1-Z(c�I
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
la
Permission is herebyC�granted to dispose of the human e ins described o e as indicated,
Date Issued L-t t') tc). ') Registrar of Vital Statistics �� _""_ _
---� (signature)
District N1(:)-C CQ LL.Q-e..4-,4D—A___,
umbeSicr) Place ( A � �
I certify that the remains of the decedent identified above were disposed of in accor ar a with this permit on:
Date of Disposition /1/1/7 Place of Disposition i , rIL 4.
(address)
(section) (lot numbs (grave number)
P son barge of Premises J w 1 �Ct.bl 6a vr1 e
(please print)
- - /-