Kulibaba, Michael . , It 37Li
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir sit Middle Last Sex
I1,ewe/ N4zA/Zs'k1,Q/i b4/2 n mask,
Date of Death Age If Veteran of U.S. Armed Forces,
Ni Ui,41 98,.,1O 1/ 68- War or Dates 1(4
Place • Death Hospital, Institution or
City, Tow or Village Coge,STr2 Street Address
tli0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ri❑Pending
1 Circumstances Investigation
W Medical Certifier Name tl Tie
0 zahN P S7a�.r-tAIeu "�
Addr ss
1b Pa2K.ST. a1PNs bills 'NY Izlo i
Death ificate Filed District N„jm�� Registe�,Number
City Town r Village S re2 .56
❑Burial Date Cemeteryt r or Cremay
;; ❑Entombment Trill A9,de l I 1 p I N G' V e&°nit!-'re-ii y
Address /�
Cremation CAAA e/2 fa (UlCr/1�SAY1 N /2e0
Date Place Removed
Z Removal and/or Held
Q❑and/or
� Address
Hold
0 Date Point of
i 0 Transportation Shipment
f3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home quA/ b. £ A/(,Er� � �/_1v024� / e_ Qf I3 0
Address 1
1) Lw fire Sr. 9tic rvysAii M-? /FfoY
Name of Funeral Firm Making Dispo ition or to Whorrf
f- Remains are Shipped, If Other than Above
,', Address
ir
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fl Permission is hereby granted to dispose of the hum\remains described ab• • - as indic,ted.
Date Issued - id1y a9, ad 1 Registrar of Vital Statis ♦ ,, ._. , 0 ,S
igna . -
/S/
District Number �-65� Place NesrE2 gum/ /,"� vrov t, t A i°�J
/,'I, 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition ilf 11 11% Place of Disposition Prvv,Vcti, e+ {oR„A...
(address)
I:U
{l
1C (section) (lot numb (grave number)
0
Name of Sexton or Perso in Charge o remises (Isi p\tr t.•ctt
2 '(please print)
1 Signature Title COP;i4'yti`'
(over)
DOH-1555 (02/2004)