Maxam, Mark H3yr
NEW YORK STATE DEPARTMENT OF HEALTH i _-_,Vital Records Section Burial - Transit P rmlt
Name First Middle Last Sex
Al/(42 k E V4A--X04-M '4
Date of Death Age If Veteran of U.S. Armed Forces,
y130)I 57 War or Dates A/O
.14 Place of Death Hospital, Institution or
ifi �3 City, Town or i lag ) ey 6-01.4,ALDj Street Address /g lock. S A70,1 (4
Manner of Death izir71 Natural Cause 0 Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
U.
ta Medical Certifier Name Title
MAizc QUA 26S'1Mt9- Mb
Address
/We 26tur 9 i Snali 6-- A/s FA-t-i-c, it y
Death Certificate Filed � District Number Register Number
:> City, Town or lifa j (-Old C�G�^N'G+fc1l s')c�-� /
€>::❑Burial Date Cemetery or Crematory
['Entombment Address
2 l l p/,y )J Lt4/ CaatiATQIZy
Cremation OK A-ice/L ad. t L11 fL.FLAJS Bolt it z .&J V. /Z &
Date Place Remo e
....Z❑Removal and/or Held
and/or Address
Hold
0 Date Point of
L`0 Transportation Shipment
el by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiil Permit Issued tPaker Func tome Registration Number
Name of Funeralllob fayette Street
C113C7
Address Queensbdiry, NY 12804
ig Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
f
tx
Permission is her by ranted to dispose of the human r- ns described abov- in 'cated.
II Date Issue Registrar of Vital Statistic: __, ,
(signature)
District Numbe;5 Place d- kl 2o - � ��
r L-1r`L
::>' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILI Date of Disposition Sidi ' Place of Disposition Li Amt.°Pl
(address)
in
ce (section) (lot number) (grave number)
Name of Sexton or Person in Charge of P emises2 G X f dt$�(ple se print)
• Si
anature _ Title (2EMt4
9
(over)
DOH-1555 (02/2004)