Hawryliak, Colleen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial
- Transit Permit
Name First iddle Last Sex
/ vi ' i`
Date of Death . Age Q eteran of U.S.Armed Forces,
111 / — 9--// I War or Dates
14. Place of Death /', Hospital, Institution or
Z. City, Town or Village 34a Vic v4 at Street Address
ilita
Manner of DeathCause Accid t Homicide Suicide Undetermined Pending
III I Natural ❑ ❑ ❑ ❑ ❑
Circumstances investigation
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Medical Certifier Name ie,/ L. Title
Address
Death Cs ate Filed District Number Register Number
`=> Cit<faii_vir Village ,tte)4.4,LA.r
❑Burial Date Cemetery or Crematory
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❑Entombment Address /.� ``/ k L 'z^ J C're..t4t' Cremation r CJ 4,,./( (91✓tr_e.✓►,s(a w .iv / ,S ,/�
I
Date Place Removed -�
❑Removal I and/or Held
and/or Address
4"" Hold
0 Date Point of
fl
❑Transportation Shipment
et by Common Destination
:iiiiN Carrier
<s': Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ill Permit Issued to Registration Number
Name of Funeral Home t 0.y na c b,-.&a.ker Fiane r of lYWt Oil 30
Address
II La yQ.+At SA. , a�eensbu (y , NJe `A.IrV__ 12 0
>> Name of Funeral Firm Making Disposition or to Whom
.. Remains are Shipped, If Other than Above
2 Address
2
iti
0.4
Permission is hereby granted to dispose of the human mains described abovve as indicated.
Date Issued r ) I,bQ!)Registrar of Vital Statistics � ` G • /1-1._�
(signature)
District Number S(.9 i;"7 Place O
I certify that the remains of the decedent identified above were disposed of in accordanc - this permit on:
La Date of Disposition 11-(t(-I t, Place of Disposition ?ill
0 rt& Crok0 r t‘,�
(address)
AU
IA IZ (section) A (lot number) (grave number)
ct Name of Sexton or Per on in Charge o Premises riSt. Jl"'
(please print)
Signature True Ca‘rhlk6t]
(over)
DOH-1555 (02/2004)