Poette, David .79°
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First sUii -- Middle l st Sex
A-v i 0 6---i3 w)9-71-1J /'o 6> > Cr .11/9't-c-
Date of Death / I Age If Veteran of U.S. Arme Forces,
/o /2- / 7 9 War or Dates i rL 1 dILc,C-
-- Place eath Hospital, Institution or (�
Z City, own' r Village Q 0 t>'?5"ic%5 Q Street Address 3 6 Z LsZ> J%R 6`��
0 Manner of Death�Natural Cause O AU cdfdent 0 Homicide El Suicide El Undetermined ri Pending
111 Circumstances Investigation
W Medical Certifier Name ----A
Title
n � f I c Q;.c.4- ,tth
Address ((�� �'
&-� Lg.-L./1 Er- , etf3.oJ.J / e'Liir f`r /Zc-0/
Death ertificate Filed District Number (e inter Number
City, I ow. or Village Q us (3 ()it �co '� �_ F I
z '. OBurial Date / Cemetery o rematoryy?
/o /3/ //CP l I/06- Va6'-3
❑Entombment Address
Cremation CD U 6-74 0 Q 0 C2s.J S d V l A
Date Place Removed
Z Removal and/or Held
❑and/or Address
N Hold
C? Date Point of
Q Transportation Shipment
El by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to } Registration Number
Name of Funeral Home . \c c ;v�(Z.\ HO�t C 11 ')Q
Address (c iZ ock
>' Name of Funeral Firm Making Disposition or to Whom
.1 Remains are Shipped, If Other than Above
2 Address
ilk
LELI
�" Permission is hereby granted to dispose of the human remains described ove asjndicated.
Date Issued
t Cs2311 l(,Registrar of Vital Statistic CL Q
l 3t t�
(signature)
District Numberc�S— r Place 7—c.; �r.N. O-( 0 L1/4___;Q J
' I certify that the remains of the decedent identified above were disposed of in acco anc with this permit on:
E
i Date of Disposition jj j t I/,k, Place of Disposition 47:14,.J cam°txl,...
2 (address)
ill
Ul
et (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises /4r'1" r SL"'"ilt
z. ( ease print)
1 Signature
a 4,,orr..:.:. Title / PAS
(over)
DOH-1555 (02/2004)