Kozak, Anne # 673 O
NEW YORK STATE DEPARTMENT OF HEALTH Burial ® ���� g� Permit
Vital Records Section
Name First Middlevast I S9),<.
.t)&" Five A)CI S K 0 2 k I //8Z
+-:_; Date of Dee' AgeIf Veteran of U.S.Armed Forces,:
t > 7o Al )7 1
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I War or Dates I 777- /ScP
Place of Death Hospital, Institution or J�f
j City, Town or i{lag so.,.) �,t�L(,S treet Addre$ 2 (o / / /97,0 S--;
1 . Manner of Death f�!Natural Cause Accident Homicide 0 Suicide Undetermined Pending
� Circumstances investigation
ill Medical Certifier Name Title
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Address/QD &RV_ (3) K 5.- 4I 76Y l 2-cPd /
Death Certificat- iled ; District Number / /Register Number
City, Town r Villag- So..) Feu_S 12 Z&
❑Burial 5 ate / Cemetery o�Crematory��
ri .� - (1.b�
❑Entombment( Address 3 7 acremation a 0 a'.Z�. � „ u-;ara
Date I Place Removed 7' `/
C Removal , and/or Held
and/or I
Address
ri5
Hold
Date Point of
en Q Transportation Shipment
by Common ( Destination
Carrier ii
Q Disinterment Date Cemetery Address
0 Reinterment 1 Date I Cemetery Address
Permit Issued to � � Registration Number
Name of Funeral Home 1 •\I`Za l t- 2.':it L,.-rx\ h rcl C:,11 ?,0
Address
Name of Funeral Firm Making Disposition or to Whom
ice. Remains are Shipped, If Other than Above
Address
M
Ill
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued v /30 ( (7 Registrar of Vital Statistics r r gi5k-,mac
(signature)District Number 7 j..6, Place �� / l 4 0 --(7 /J4, 04.6,i1 (- l/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lL Date of Disposition ")/3l J� Place of Disposition ,r,i 17‘4.,,,
a (address)
la
In
c (section) (lot number) C (grave number)
ci Name of Sexton or Person in Charge of Pr ises +pl
Z, (pie-Abe print)
Signature4 Title OEMI
11
(over)
•
DOH-1555 (02/2004)