Macewicz, Sigmond •1 . k
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First r MidoIle Last I Sex
Date 1 ath
m., 1 9_1mD _ vi(JA.a.ir 0 in4avvi cp.
Date of Death I / q / 0.. Age If Veteran of U.S. Armed Forces,
:.•'": War or Dates —
i4. Place of Death u Hospital, Institutiq or, ril 1 1 rn ,,,
2 City, Town or Village .Ititt caliS iNti,410111, Street Address (ItS -MIS Mel MI TOIL'3rittt
14
a Manner of DeathK Natural Cause 0 Accident 0 Homicide 0 Suicide ri Und termined ri Pending
Circumstances 'Investigation
8 Medical Certifier Name , Title
o -Va\I A (tA AAAutV16K VW-1S>
Address ,-)
5 I ro 7cuit CrAtauf g1e4AS -14 I) c.)..Alew Ya r.(
Death Certificate File District NumbiLv Register
City, Town or Village ItitS41/Mthi OA
itgi
t.2 .490/
E Burial 1 Date 1 ict 11.... Cemetery or Crematory r
Address I
- lij IN Ur011kah‘f (
11gCremation (_QX V-OCUA Date Place Removed t)
QU..709k-rIN iiki-Chl YOY r
Removal V // 7.
. A 0
1 and/or Held Li fAs tkil E ilyl -4, i
114 and/or
Hold Address
O a ( S-I-r-eLf q-tiks iiis ,,Alefril Yo-r/C
O Date I Point of
05 Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
•::: 0 Disinterment ^
Date Cemetery Address
EReinterment .--......__
Permit Issued to Registration Number
Name of Funeral Home _ .,_ Kt.:;kt.R N 6 A - 01i32
Address /
I/ Li)-- 111.--) 1 Z-_-;-- Ci 0 oa.,---,,)s a ur Aiy, /2x--fi ti
LE N9fne,of Funeral Fiern Making Disposition or to Whom V- i .
Remans are Shipped, If Other than Above -
14 Address
W
• Permission is hereby granted to dispose of the human remains described above as indicated.
ail Date Issued 1 ) 6/ 17 Registrar of Vital Statistics LA)QA-A.1-••Ka•
(signature)
District Number 5'6 o 1 Place b CZ/v• C rtA h S, a...)
:.:.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i• Date of Disposition h°fil Place of Disposition
Ens:0 li.--/ am 4i 0 r 1."--d
a (address)
LU •
(/)
CC (section) iyflot number.. (grave number)
o Name of Sexton or Person in Charge of Premi es • 14 171,1,- J 14 A lit
Ci
2 (please print)
Signature .,t Title Amigo 4
- (over)
DOH-1555 (9/98)