Fisher, John Y ,rl 1131
NEW YORK STATE DEPARTMENT OF HEALTH - Transit P�rmit
Vital Records Section Burial
Name First `^ ��M'id_d�le Last Sex
`n � �� k
Date of Death Age If Veteran of U.S. Armed Forces,
U L\\a.5\20I (It' War or Dates v\1✓J IE
14, Place of Death �t Hospital, Institution or
City,Town or Village �C lens Pc c i 1�1,i'aiL Street Address 3 (Liacre. 9-reekI(
Manner of Death®Natural Cause 0 Accident Homicide 0 Suicide r7Undetermined Pending
Circumstances Investigation
at Medical Certifier Name Title
f1 •
/ il OrY1 4.0 CoppTi MD
Address
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DeathOertificate Filed • District Number Register N mr
City,Town or Village i.5-6,/
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❑Burial Date Cemetery or Crematory
:> El Entombment Address
: Cremation (�w (La Q,,ks__ci i M`:I• I�c..)7
• Date Place Rem ved
❑Removal ' and/or Held
and/or Address
F ri Hold
feli Date Point of
Q Transportation Shipment
f3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
:<El Reinterment
a Permit Issued to Registration Number
il Name of Funeral Home f3Ai*A. fuiJ kARL 1,10ett. 01i o
: Address 1 I 1 AAki S77- 6 u't 0N S 6Je Cl a_ )Z WI. 0I 13° •
:> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human r,mains described bove as indi ted
iiii Date Issued Q "101 p J 7 Registrar of Vital Statistics * / .. Ai
.. 4 1,
/ (sign., re)
District Number t�0 r Place C 2fr' -1�Z 1
' I certify that the remains of the decedent identified above w- disposed of in accordan with this permit on:
pp
Date of Disposition 51L`n Place of Disposition 'Irot1Jlt� �.�. (-oriv._
(address)
tL
al
lZ (section) lot number) (grave number)
lit
Name of Sexton or Person in Charge of0. P emisesZ ��s=s ' �t''I
et (pl print)
Signature 4Title
(4 MD 1
(over)
DOH-1555 (02/2004)