Vega, Robert NEW YORK STATE DEPARTMENT OF HEALTH . 7��
Vital Records Section ,, Burial - Transit Permit
Name First Middle Las Sex
CE2Mbiert-t- oAv--_ yyva *,2.
Date of Death c? i Age t� I-Veteran of U.S. Armed Forces,
b �� -l� War or Dates () ! a
4. • e of Death Hospital, Institution or "r I� \L .'
own or Village<4outs Q Street Address L Q ` a YIA-rLs � Y,
:O. 1 anner of Death❑Natural Cause Accident Homicide Suicide Undetermined )0 Pendi g
Ltd Circumstances Investigation
Ltu 3 Medical Certifier Name V.,,‘Skii\ ( Title �'.\D
Adltz ( �,b,`�/v (f5�0.1 WQ (1 - S r0 l SLe , Ik\V
ath Certificate Filed �` Dish
Umber Register Number
City, Town or Village ��(tic
Iv / h
Mi Burial Date � / metery ior)Gtremator
Entombment (.6 — P 2 6\: )�3 " f Q (rcovo‘.../h �-'Addressh(J� t
Cremation -U ty/ U�t �1 V f L�U
Date Place Removed
Removal and/or Held
and/or Address
i=`` Hold
try
O Date Point of
0` Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
giiiEl Reinterment Date Cemetery Address
Permit Issued to \� `n iy 1�j „ n Registration Number
Name of Funeral Home ? Qn Jo. 1 n L (S4 I i I-.g �(1l(/ )141
1
Address �/ � �/�(� �Q ����- ,
1 Name ofs Do l�il, kk r _ 0,0,a_etu bU / r 1 1 �16 q
Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
Lu
Permission is hereby granted to dispose of the human remains described above as indicated.
II Date Issued IIS(1 Q( ..o 11 Registrar of Vital Statistics `i 421,421.4 ....
(signature)
ii District Number •3300 Place (BOUNTY OF ONONDAGA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ill• Date of Disposition /a al Place of Disposition Zits t,.,,.c.40r�
(address)
to
cc (section) (let number (grave number)
Name of Sexton or Person in Charge of Pr miser Ao 3H,444
( ( lease print)
::: Signature L ✓'� Title at M .,
9 � +� I
(over)
DOH-1555 (02/2004)