Loading...
Pecor, Donald , . _ . , # 0, glio NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Nam First Middle Last Sex oon id C Pe,c © r Ain Ic mi Date of Death Age If Veteran of U.S. Armed Forces, iig q - 1 1 -7 0 War or Dates M c Place of Death Hospital, Institution or _ Cit1y_, Town or Village , ens - ids Street Address C�� f c� . s k I G ( sy c Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Iti Circumstances Investigation tu Medical Certifier Name Title Mr'vin Dc2Vid7uJ , tL fr16 Address Do Pa_f-k SI- GIen3 Rib NY Death Certificate Filed District Number Regisjly`urji er it Town or Village 61 c ns 1a I Is , tot)tot)/ �� si ['Burial Date//�� C meteryorr CCrematory ['Entombment c`e_ ©(0 .- `'4 0 / 7 I , ✓)2 V,e Zt rc etie2 Address Cremation r l.t o` 5{-J- J NV Date Place Removed ❑Removal and/or Held and/or Address a: Hold tip { Date Point of ti ❑Transportation Shipment 2 by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address iiMi Permit Issued to Registration Number Name of Funeral Home B re i,t.`er r-utr)e-f?L/ 1-- Q"7t //i c 0o -// `' Address c'g,1-- NW-di( It . La i. e.- LLLZ . Ay I *67 mi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ';! Address Ili 1.7: Permission is hereby granted to dispose of the human remains described above a_s indicated. ,, Date Issued /&JJ Registrar of Vital Statistics ()�+_,Lkley 1.� (signat District Number 5/ rt / Place (i O-r 6 1 e n..5 / Its )- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 ILI Date of Disposition 4tIf tt1 Place of Disposition fmc(I0.-, ' ,.4-toc --- (address) Iii tf CC (section) (lot number) (grave number) 0 42 Name of Sexton or Person in Charge of Premises ��v S ^Lb� ® (*lase print) Signature Title MYr I`t'lL (over) DOH-1555 (02/2004)