Jabaut, Wayne NEW YORK STATE DEPARTMENT OF HEALTH 14 377
Vital Records Section Burial - Transit Permit
Name First 4 dle 1 t A) iC riellihiv,) -te,g 19-01- \ S x
Date of Death �1d13/? Age1 If Veteran of U.S.Armed Forbes,
(f I War or Dates AV 6
ce of Death Ho itaS. institution or
Ci Town or Village C(,l .ys F - Street Addr / 1L-)l , 77-
111
+o Manner of Death c7,120atural Cause ❑Accident El Homicide 0 Suicide El Undetermined El Pending
14,1
Circumstances Investigation
Ili Medical Certifier Name Title
PI ha t. &vf�ti Ph
�.c*. ySI ua.n
Address
LI% E S- .) f l . ECi Wa-r CL ,N`1 12 S Z'
IV-th Certificate Filed District Number Register Number,
own or Village C� AI 3 ram,(, t i %0I
❑Burial { Date Cemetery o Crer orC
t 2 f/g 7 f ) 137.0
❑Entombment Address in ,{
remation C () /976�-- 1L2U ti ^r3 Un-xl
, ) L
Date 1 Place Removed
C
Removal f l and/or Held
and/or Hold l Address
in
0 ' Date Point of
cil ❑Transportation Shipment
5 by Common Destination
Carrier i
:- Disinterment 1Date
1Cemetery Address
Reinterment
I Date 1Cemetery Address
Permit Issued to . r-' Registration Number
Name of Funeral Home 1 A/ry-- t--� c1La -\ Ho n-- C i l • 0
Address �.-: -.
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
!
III
! Permission is hereby granted to dispose of the human remains describe above as indic ted.
Date Issued o4/�Q/�G/7 Registrar of Vital Statistics \\, ���� G .
( ( (signature)
District Number 6/60 Place4,--16171-C ,�=�� '?
I certify that the remains of the decedent identified above were disposed of in accor, npce with this permit on:
Lid Date of Disposition t//171n Place of Disposition 'p�ic Li t iri-_
(address)
Ui
.01 number)
I. (section) (lot number) (grave
0.
Name of Sexton or Person in Charge of Premises r`s '`'"tit
Z !ease-Pint)
to Signature Title !4 ni P-
(over)
DOH-1555 (02/2004)