Sycuro Jr., Astor • c li
NEW YORK STATE DEPARTMENT OF HEALTH li 35i,
Vital Records Section Burial.- Transit Permit
Name First Middle La Sex
QS�oZ �'5T,,, J�
c;,,C`p _ /v,h Le_
Date of Death Age If Veteran of'U.S. Arme Forces,
Sly l a,r7 g War or Dates 1 `I'> 7 1‘`i
- 14 f Death
/ - Hospital, Institution or
cept
City wn or Village �LGn>'-T l�l'� Street Address (off.-c,r., -T 4-? -�
Manner of Death Natural Cause �Accident �Homicide Suicide Undetermined Pending
VCircumstances Investigation
W Medical Certifier Name,-- Title
O. )�^^' � sett /'"\ /IAD,
Address •
cam, sZ G /�t�-- � N 7 s of
Certificate Filed // District Number Register Number
:ilf City own or Village C.96^5 i.(L--- SRO°, . _3-O
DBurial Date /� 7 Cemetery or Crematory ' •
`Q Entombment / 1 d 5 ' ��( 1 , it c v,c...., �fc,.,-c-vr e
Address
•
NCremation N v A
K.Ltn7 Ulr Lw /�r/�
Date J ` Place Removed
Z❑Removal and/or Held
and/or Address
"` Hold
U7
0 Date Point of
Q Transportation . Shipment
Q by Common Destination
i Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Homei ._l 4orC tier
.1. 1--(�--c,- , pa y�
Address
AN-v. Ate , C APT /�, >—
: Name of Funeral Firm Making Disposition or to Whom
.14 Remains are Shipped, If Other than Above
2 Address •
Ill,
Permission is hereby granted to dispose of the human remains descri' d above s in ' ed.
Date Issued VS---46(--) Registrar of Vital Statistics ‘-/ -
(signature)
District Number 5 6v/ Place �a,n5 e-1-.0k I (f ) A'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition cj ll I n Place of Disposition Ctxt 04.4.1 1..,r•. C!'L� .
(address)
LEI
CC (section) ,/(lot number) (grave number)
ci Name of Sexton or Person in Charge of Pre ises /4r-i } tlAti
A' (ple e print)
;: Signature Title (Ze '!RL
(over)
DOH-1555 (02/2004)