Sopen, Michael . 01
NEW YORK STATE DEPARTMENT OF HEALTH.. _ p
. Vital Records Section Burial.- Transit Permit
Name First Middle Last Sex .
/t ck ., (r).r.r:\dTorces,
imi Date of.Death Age If Veteran of.U.S.
a/ 7/ �,,ii 7 War or Dates
- 14 P ce of Death Hospital, Institution or i Town or Village $L Street Address 6L °
0 anner of Death 0 Natural Cause 0 Accident Homicide' Suicide Undetermined Pending
UCircumstances Investigation
Medical Certifier Name Title
• , . h mkt) A t,,ht,A. M,-
Address 0 J kt A �1 U Y
P Register Number
,, Certificate Filed �. �istnct Number �G,�� g �7
iiiit i own or Village � c#, • •
iiiiii!:':, ■Burial Date Cemetery or Crematory •
a. / I /a..-t7 ,nr v:....,
❑Entombment'.Address
v
Cremation v.een5.5-1( 1 06,, /r,r/k --- . .
• Date: ; • (J / f Place Removed
Z.❑Removal and/or Held
and/or Address
►, Hold
VSDate Point of
O.
F ttiQ Transportation . Shipment _
:Ct by Common Destination
iiglIk Carrier .
0 Disinterment Date Cemetery Address
.. El Reinterment Date Cemetery Address
`<::>> •
!ii! Permit Issued to — —� _ Registration Number
• Name of Funeral Ho . ..-AsMd rc I -c.r..( 1+v,-e._ — O c,`i"4`((r
Address
7 &erM.., 4, • • /J7 f . a
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address .
t
a: Permission is hereby granted to dispose of the human remains<'' 1
descried above sin ed.
Date Issued :D. //7 Registrar of Vital Statistics �-
(signature)
°< District Number j 0/ Place ‘Z.a.Afl--'&I (,c ) /i
illi
iti.! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l'WW Date of Disposition ZI i,/h Place of Disposition 1i x t9 (-. tOr'.—
2 (address)
tt1
44
(section) //b�lot number) r (grave number)
gName of Sexton or Person in Charge of Premises /flr,S-}plr- ishntrl
(pie se p Cal MAXint)
w a ./48)Signature
TitlMA
(over)
•
DOH-1555 (02/2004)