Young, Andrew NEW YORK STATE DEPARTMENT OF HEALTH r 4 p B 7�D
Vital Records Section urial Transit Permit
Narrn Fir t Middle Last Sex J
! )CI -1 cv /lc Mat' Date of Death Age If eteran oft . Armed Forces,
1444
1 0 ) (4 c C'f -7 5 War or Dates �f
Place of Death Hospital, Institution or
City, Town or Village A Lu 7' r'7 Q Street Address 75(p /./ r/` a
Manner of Death FJl Natural Cause 0 Accident 0 Homicide Suicide � Lndetermined Pending
5�°a Circumstances Investigation
Medi al Certifier Name Title
Alikl nct.;,va_r\ D
Address
fi,' N)C r1/41--9\_ 0.1 ..g QA._ N\i
` Death ificate Filed District Number Register Number
0 City, r ow Village 1X kJ Li ze r n ar5(o 7
❑Burial Date cn etery r Crematory
I 0-- i IC - 1 --/ ti ne V i(i.0(11"arfl—C Ill
❑Entombment Address
is Cremation 0 LtLLQc Z loui.,r-Z, �'7
Date Place R moved
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
VI
ill Permit Issued to _, Registration Number
Name of Funeral Home rst `� t_ . ' !t .� Bat" ` 4
Address
: °91 el-klkrr St L1_L Ct itrrx ` " 7 ia34-6
01 Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
Address
x} Permission is hereby granted to dispose of the human r ains d cribed above as indicated.
0 Date Issued �,E)1l� \ ri Registrar of Vital Statisti , L8
(signat re)
Er
District Number 5 Place !o ) 1_I,t 71 ,r ink
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition join In Place of Disposition F,,L G-•ncefo r,a,,
PSI (address)
(section) 4(lot number) (grave number)
a 's Name of Sexton or Person in Charge of Premises G '1r � — Se't�,4.
(ple print)
Signature 4 Title r mIT
(over)
DOH-1555 (02/2004)