LaVergne, Matthew NEW YORK STATE DEPARTMENT OF HEALTH' 'IL
Vital Records Section Burial - Transit Permit
Name First Middle Last S
Mct I P , Li Ve rC► lilaxx 16
Date of Death Age If Veteran U.S. Armed Forces,
3•- —J -1 :�? 9 War or Dates Ajo
1-- Place of Death Hospital, Institution or / -
W City ,or Village Jots tlf.3b r'G Street Address J) i3�h Lt , k 4
Manner of Death D Natural Cause 0 AeCident D Homicide 0 Suicide riUndetermined Pending
W: Circumstances Investigation
W Medical Certifier _...1--Name Tit�
l t rrti I'1 Coma « (Orziprr
Address
Death Certificate Filed District Number Register Number
City, �ww Nor Village , 1c�hr 5 tk 5( ,
❑Burial Date metery of Crematory
DEntombment 0 . C -- 7 1 1`}e V )f' .) C,/ e n«L.*h
Addr
Cremation �tis.Q n S'oik
Date I Place Removed
ci❑Removal and/or Held
and/or Address
F= Hold
to
O Date Point of
ftQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
:ivPermit Issued to Registration Number
Name of Funeral Home N,1 i 1 - , ,,ra__C 1/11_Q () cl
Address
t31 Stiff az 50 1nri ( «d' !ak Mf /Z$f2-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cr
lU
1 .• Permission is hereby granted to dispose of the human r ains described above .ndicated.
Date Issued .'�— 5 i') Registrar of Vital Statistics L., bq ,
/ef (signa ure)
District Number5(t35cc Place „..... 1-sANN...c\r. u. .
I certify that the remains of the decedent identified above were posed of in accordance with this permit on:
tu Date of Disposition ��j�{j 7 Place of Disposition j���, L/e -/-o�
2 / (address)
iii
CA
CC (section) (1 (lot number) (grave number)
O Name of Sexton or , r o ' Charge of Premises J t-/IC,- '- 64.✓rca-` F'
2 / (please print)
iLiSignature Title G-1e- e-Iris
I
(over)
DOH-1555 (02/2004)