English, Norma NEW YORK STATE DEPARTMENT OF HEALTH 60
Vital Records Section Burial - Transit Permit
Name First I /Middle Last Sex
AD&/`1/.9 l! 1 ti1 E3J cis FL-396E7
Date of Death ) I Age If Veteran of U.S. Armed Fo es,
(a MIN' I '7S War or _ iJ
}�- Place • -ath Hospit I, Institution' r )
Z City, own •r Village &Oar-Ass-Q ut - - Street A dress I ,iiir 'j /�!T-d..�
p Manner of Death. latural Cause 0 Accid 0 Homicide 0 Suicide Undetermined Pending
tit _ Circumstances Investigation
W Medical Certifier Name Title jc
a ae.U SL_� 30ALA(_ �—
Address /3-2... (A3-)--6\,,,,viot..,) Ak'---.
J 1`, , i / ZFU/
Death rficate Filed D rict Number R is r Number
Cit Tow tqY Village (j&- �S 6J
❑Burial I Date I Cemetery oCremator
6 /y / pl,,,, V, 6�
❑Entombment Address � (
' remation U?9� � U �7 V �/ / �'
Date Place Removed / %
ZZ❑Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N0 Transportation Shipment
Et by Common Destination
Carrier
El
Disinterment Date 1 Cemetery Address
Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Is'ickyncu d 0. (Suffer 1�uriCr cL1 kOCYNI- 0 i I LA G �
Address
takkyq He -A . , u.c.ensloury , tiev,3 ~/u4 k_ 12SiC0--
—
Name of Funeral Firm Making Disposition or to Whom
I_- Remains are Shipped, If Other than Above _
Z Address
IC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Lot l Registrar of Vital Statistics Sc _ G d.R '.
(signature''
District Number S7 o `l Place
F- I certify that the remains of the decedent identified above were disposed of in Gordan a with this permit on:
Z
LLi Date of Disposition is-‘5-1t Place of Disposition Irtt0„v.) C lociuN.
2 (address)
W
SU)
W (section) l number) �` (grave number)
g Name of Sexton or P4L_
n Charge of remises ar:si:F/er eow&
Zease print)
Signature Title __ ('(� fokrog,,
(over)
DOH-1555 (02/2004)