Peceu, Jeffrey f t" 9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First .— Middle last ' Sex
Jecc,(e\I Te4er WCe�
Date of Death Age If Veteran of U.S. Armed Forces,
ak I D5 1 CO (9 0 War or Dates tic17'I - 1480
Place of Death Hospital, Institution or � lens „� IIS �Os�i
ity, own or Village G I eYZS r01/411S Street Address
p nner of Death Natural Cause []Accident El Homicide 0 Suicide Undetermined ❑fending
lU Circumstances Investigation
W Medical Certifier Name Title
o Na\)-)er1 S;d6 ;g1);
Address
IOC %r\L S ee - G erS .Pa\\S) JJ1 IZBO\
Death Certificate Filed District Number 1 Register Number(g
Ci ,3own or Village C 1 ems Fa11,c 50 01 p�
El Burial Date Cemetery or Crematory
Dy 1 Ol / 20l(--0 7)irie UieuJ Cce,mci--crrsj
El Entombment Address
1Cremation �P��C1.Sb iyr 1 Z8 +
Date 1 Pla Removed
Removal ; and/or Held
...,, and/or Address
N Hold
.3 Date Point of
0 Transportation 1 Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Home )o wer �unec--a\ i-tc rr'i€ C.)\ 1 3 O
Address
1\ t.-acc,\I e\--Ve_ 5\ ree4- C .)eer c o r y , ,i'DI 17.1309
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
.. Permission is hereby granted to dispose of the huma remai described above a= ted.
Date Issued ";Y��� .�1}/� Registrar of Vital Statistics 7 g -, c� �-r�
'� (signature)
District Number r 7 Place [.-
I certify that the remains of the decedent identified above ere disposed of in accordant with this permit on:
ILI Date of Disposition K /bf1 Place of Disposition etteil al.,' r 'torte.,
X (address)
fin
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of P emises (ram 3
Zr (pi se print)
141 Signature Title /t44taL
(over)
DOH-1555 (02/2004)