Stefan, Peter NEW YORK STATE DEPARTMENT OF HEALTH E # 153
Vital Records Section " Burial Transit Permit
iiili Name., First - Middle Last Sex
giiii s Date l- th A Age If �� r Ma 1,
Veteran of U.S. Armed Forces,
—2-0 /-7 7 0 War or Dates K
. 44 Place of Death Hospital, Institution or
City,( .ow or Village I► 1CJ1 u;r1 „Kc. Street Address
Manner of Death al Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
ta Medical Certifier Name Title
bona ToLonse Lc� Cor or * f
Address
g , i
> ; Death Certificate Filed 1 ,, \IY District Number Regisr Number
City, Town or Village I fCa1.a_y) 1_a_4( Ir cQO63
` < ['Burial Date etery or Cremato
❑Entombment Addre /� ,
Cremation unsb � V
Date J Plac Removed
Removal and/or Held
9 and/or Address
1= Hold
In
Date Point of
014 Transportation Shipment
by Common Destination
11 Carrier
`' Q Disinterment Date Cemetery Address
_' 0 Reinterment Date Cemetery Address .
iiii> Permit Issued to Registration Number
Name of Funeral Home M i +cr - 1)e...,rai ()Ogg c1� .
'<> Address
Name of Funeral Firm Maki g Disposition.or to Whom .
Remains are Shipped, If Other than Above
• Address
tr
ill
.57 Permission is hereb i granted to dispose of the human ains described above as indicated.
;< Date Issued 311 17 Registrar of Vital Statistics Ljej 0
(signature)
<' District Number 9Q53 Place
1n o ' l ndrati Lai
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z"'
tLI Date of Disposition 3/ /7 Place of Disposition 2,. ?e \l`t;) > L'/&n'i ah r
/ (address)
ILI
Ca
CC (section) (1 number) (grave number)
Name of Sexton or Pe 'n arge of Premises / �6.911,c,,✓VIC4 G
Z (please print)
i Signature :�`� Title C/-g- 4.-4o
(over)
DOH-1555 (02/2004)