Polunci, John NEW YORK STATE DEPARTMENT OF HEALTH # g 5—i
Vital Records Section Burial - Transit Permit
Name First MiddleDin Last . S x,
T50hn 1 ciIun 1 a .
Date of Death Age A If VetVrctri of U.S. ed Forces,
� �- x-/ - ) (..p -7 " War or Dates I4m�-- 1 j(p4-
F- Place of Death Hospital, Institutio or `
Ci , Town or Village :015 _r-tI,`_5 Street Address �j �u. �S I 3
a Manner of Death r7lin Natural Cause ❑Accident 0 Homicide El Suicide ❑Undetermined n Pending
Illy Circumstances Investigation
la• Medical Certifier Name Title
C'
Address
th Certificate Filed � Distri t Number Register Number
Cif Town or Village C leis Fa 115 (DC)I 59 I
IDBurial Date Ce etery or rematoryy
❑Entombment 1 a 9 - I (P y- H Vl e " i c to p'mY I o
y.
Address
`Z]Creniation- QW2k nSlunJ /V
Date Place Removed
Z Removal and/or Held
2❑and/or
� Address
{n Hold
0 Date Point of
fki❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
s Name of Funeral Home zit ,r fy ,i -{-rr au 'h L Oo /J
Address �t c.. � /
�
`� aura) L .i- l t-nk I n
.,y
Name of Funeral Firm Making Disposition or to Whom
f;; Remains are Shipped, If Other than Above
', Address
lL
1,"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued is )Z6/20 16 Registrar of Vital Statistics CA W
(sig./
District Number 3 6® ( Place 6(Q,,,S 1'o\S Ai /
r
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tit Date of Disposition l/J30 10b Place of Disposition s4ust•.. ( aiv..
2 (address)
IW
U)
CC (section) / (lot number) (grave number)
Name of Sexton or Person in Charge of Premises tir:s Stlli'll
lease print)
LLI Signature CI % Title ( 4
(over)
DOH-1555 (02/2004)