Yagy, Mark NEW YORK STATE DEPARTMENT OF HEALTH e- h
Vital Records Section Burial - Transit ermit
Name First Middle Last Ni a Sex A
...-' i] Date of Death Age If Veteran of U.S. Armed Forces,
12 l- I Z Oi 1- War or Dates
E. Place of Death Hospital, Institution or
City,Qown br Village P r y y O Street Address 1 2 - rO L JQ S (�I u�
W.
Manner of Death L.67 Natural Cause Accident E Homicide Q Suicide E Undetermined �Pending
�! Circumstances Investigation
at Medical Certifier Name 1 Title '^
• 6a lct 4 �jr"• Gt �l OA ( , rrN t .0 .
Address
< Death Certificate Filed District Number Register Number
City, Town or Village I r.6j s \t S 1- 5o 3 3
❑BUflal Date I I Cemetery or Crematory t-v�
11 V Z O t n e ; ,.) ( C. nr tom: '� J
❑Entombment Address
Cremation U1uc,N ((load C weer\S\DIA ) ( 12S'OY
Date Place Removed
0 Removal and/or Held
and/or Address
i= Hold
1
0 Date Point of
ti Q Transportation Shipment
CS -by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
gig Permit Issued to Registration Number
Name of Funeral Home Pri \Lk\r.o r- R e Q \-6 'C } C) -4-9
Address 2
iiiiiii Name of Funeral Firm Making Disposition or teWhom
Remains are Shipped, If Other than Above
Address
li.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued [t 30 120\1-Registrar of Vital Statistics Steg, r jidA.41,..,
(signature)
igi District Number 5]- Se Place I ()LA.) (...\ cS- 1--,, LIZLQ, .
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition /Z 1 I in Place of Disposition f,,L i4,,.r4,7tor;_„/
E (address)
44
II (section) / (lot number) (grave number)
Name of Sexton or Person in Charge of Pre ises G��,. j'it'
/ (pill::print)
I Signature Au i Title LPFt+I'1
(over)
DOH-1555 (02/2004) '