Shevlin, Kevin NEW YORK STATE DEPARTMENT OF HEALtH
Vital Records Section - Burial - Transit Permit
Name First )�6-UTA) ViErr Bliddie ��'ra-lJt,/_4_) 1 st I X.e-zcc
Date of Death I Age If eteran of U.S.Armed Forces,
k// q/1? , 6 9War or Dates Al6-
1 Place o •-ath Hospital, Institution or
l City Village , 2ciev 3 lidn:.i SU�a,rc Town •r a reet Addres � j
• Manner of Death N Natural Cause 0 Accident Homicide Suicide Undetermined Pending
LI Circumstances investigation
ta Medical Certifier Name Title M
g //1-6 OD 0 20 S LII S ./< (...)
Address C
;<s Dean. -ri -sate Filed I District Number ' ister Number
-< City, own %r Village ,O I�6,6-U I 5 3cd
❑Burial 1 Date / Cemetery r Cremato
❑Entombment! (v` ���/ �A.)Fi"" /(-1LJ
Address
.,, remation 0 i)a k or._... 124 . (:- 06-er.,is c tlyt7 10
Date Place Removed
El Removal and/or Held
and/or Address
COHold
.0 Date Point of
cilQ Transportation Shipment
by Common Destination
Carrier
`.- Disinterment I Date Cemetery Address
El Reinterment I Date 1 Cemetery Address
Permit Issued to i-� Registration Number
Name of Funeral Home L�.l'iE'-r- \ :IL(Z\-\ HO rn t- I C:-:11 >0
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Gl-
Permission is hereby granted to dispose of the human remains ribed ve s indicated.
Date Issued O laO'4,9-0(7 Registrar of Vital Statistics Vita q
" signature v
District Number gapD Place l�3) p9,1710 kis ieI (arm/ft Yt4, 1�7)-a
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f l Date of Disposition 6/Z/ it Place of Disposition tPple v i�,v U2 'zf
a f (address)
Ill
ice, (section) (lot number) (grave number)
• Name of Sexton or rso - Ch rge of Premises --1 -k�g-n C-o IcCG'l"Q
Z (pie se print)
to Signature Title e'-/-e-in, -
(over)
DOH-1555 (02/2004)