Pasco, Larry NEW YORK STATE DEPARTMENT OF HEALTH F 6167
Vital Records Section Burial v Transit Permit
Name First Midi4le Last , I S
A.0 6en /3 6-c I%�9Lc�'
I ,!: Date of Death -1 Age 1 If Veteran of U.S. Armed Forc s,
>;::: / z / (o/4 ST 1 1 War or Dates ,J/i
Place • 'teeth Hos ital, Institution or yy
Z City, own r Village )/ UYL/-1,9,J treet Address 2.`� i263 � /4 _
® Manner of DeathNatural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
ua Medical Certifier Name r Title �yic,�n
CI ri'1t&e)I CilIHank A+I-C.r i1rtq
Address J
I01 Park Si-•) PrGcyn Pavi I ►cn, Cl lensFail&, Mi i-n01
Death ificate Filed District N_um 2er Register Number
City, own Village 7 - _„ ,J 1 bLQ
OBurial I Date / Cemetery Crematory
lites-2--
• ❑Entombment( Address + �
remation U?47Lb� I� 0 Ur/vJg / v
_ Date I Place Removed 1.
and/or al i and/or Held
2 Address
F., Hold
•0 ' Date Point of
fai E Transportation Shipment
6 by Common Destination
Carrier i
Disinterment 1 Date Cemetery Address
_'< Reinterment
Date Cemetery Address
>: Permit Issued to iRegistration Number
Name of Funeral Home &.\I'�C L;1L.Zl� HO 1 t- C�:11 e-I C_
Address r.
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
It1
Permission is hereby granted to dispose of the human rem 'ns described above a indicated.
Date Issued A.,la D///p Registrar of Vital Statistics Ia ,n,L2 _ ar_e
(sign re)
District Number 5 51 Place 3// 4 / ,q 4.66/ N� t_syD
J
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1,11 Date of Disposition 12411 I,,, Place of Disposition ;,u( + et ort,.,
2 (address)
01
E (section) it/ (lot numbe( (grave number)
O.
Name of Sexton or Person in Charge of Premises IA r+jl; /b`
2 /'/ (pie-lase se print)
• Signature et Title oI�ITtDL✓
(over)
DOH-1555 (02/2004)