Peceu Jr, Harold NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sr, Sex T
ka\ro1 d E/anS PeCe 0 I"
Date of Death Age If Veteran of U.S. Armed Forces.
OSlDSIaolw (0Lp War or Dates 11:Wa- ICI 7S
P_: e of Death Hospital, Institution or
�i� own or Village G\eo5 paI\S Street Address G►-et1S Fa11S ttUS ei kJ ]
R Manner of Death ElNatural Cause Accident El Homicide Ej Suicide riUndetermined 0 Pending
Circumstances Investigation
E. Medical Certifier Name Title
o N o-N ed Sdd ;10 M
Address
WO SC,r\L S\--• .0)JeeY,s\r- v.r 7 ) iJ NI 12$(� 1
Death Certificate Filed District Numbe //,� Register//Num er
City, own or Village G I ens SANS rDpe/ //-74
.. Date Cemetery or Crematory
::< ❑Burial ) ob /a01lQ 1 r\Q v.Ie Cr-2rnai&ty
Address .
ISI Cremation &gx e r atod Qcensboiy , Kl -I 12B0-{ .
I Date - , Place Removed
. Z❑Removal I and/or Held
2 and/Holdor Address
Q Date Point of
gis Q Transportation , Shipment
D by Common Destination • •
Carrier
['Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to _ _ I Registration Number
''< Name of Funeral Home _ ><}Kv�.. .0LY;.43-� 1 ,iL ( Q/, zp
Address /
8 Li 4,7 /L` Cr. 0062::.uS g or -A , l t
igiii Name of Funeral F Making Disposition or to Whom ,- ' -
Remains are Shipped, If Other than Above
Pp
Address
>` Permission is hereby ranted to dispose of the human remains describ d above in d.
Date Issued 03 Q,T 20/4 Registrar of Vital Statistics � �
(signature) J� �
Iii District Number S60/ Place olety J /� Go i /01
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3161(ib Place of Disposition 1/4 r�r'""tforn /
2 - (address)
III .
CC (section) A (lot numbr) (grave number)
Name of Sexton or Person-in Charge of Premises • (h i1velYr•" ••JCa.t*
Z (please print)
4! Signature Title ( ►I► tQ2.
- (over)
DOH-1555 (9/98)