Hatlee, Mark flir
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name Fiat// j Middle Last Sex
Date of Deat Age If Veteran of U.S. Armed Forpr,
0 /a/fib/ // War or Dates
1h- Place th �-j / Hospital, Institutio%,or, /need iC Q
CityIli , own Village //'► / � I Street Address ./YC�t'V(GlY,cctc/c (:,.2 ,- --7-.-&1
W Manner o Death O Natural Causeccident O Homicide El Suicide El Undetermined O Pending
Circumstances Investigation
tii Medical Certifier Name Title
�"cr 79 (�/ S ,!.��2i k / Cocvr7.a-i ,
' / ;,7' .7(// / 7/�
Death Ce Oficate Filed / // District Numbe Registe ber
City, own, r Village/1/, -� . ���� C 4
OBurial Date y or Crem�atpry —/
['Entombment 7/ / ,��/J/ 7 7,e //l t'6,C/ (�-e/lLs/c'I/i/�
1 Address /�,✓- ( 6 ' / t�/�c b
remation (�J // �/ ./% �
Date Place Removed
C ORemoval and/or Held
and/or
— Address
to Hold
0 Date Point of
t1 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Ni Permit Issued to Y6 Registration Number
Name of Funeral Home Ig/ )-I ( (i/le'/iCk 1r/J7fv�-e7/ '6 w Ge7c/
Address _
%�.-e �/^ %� /147)-,„47, y /2 e2
Name of Funeral Firm Making Disp Cosition or to Whom
1. .. Remains are Shipped, If Other than Above
Address
cr. , -?
to
e` Permission is hh eby ranted to dispose of the human r -ns de bed above as indicated.
Date Issued,./_ /7 Registrar of Vital Statistics . 7 n
/ , (signature)
District Number /.. --- Place 2 /41/4,
1--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ill Date of Disposition I W O Place of Disposition f?1 6vv-cul ,__.,
2 (address)
liil
CC (section) �t number) (grave number)
Name of Sexton or Person in Charge f Premises r�� Sw4Q'
(pleant)
Signature �t Title0€14134— tie
(over)
DOH-1555 (02/2004)