Matraw, Jay N.
NEW YORK STATE DEPARTMENT OF HEALTH k g-b
Vital Records Section Burial - Transit Permit
Name First _ Middle Last Sex
-J Av Ze rfiOkY � M(II-Y-a k/0 ,
Date of Death / j Age I- If Veteran of U.S. Armed Forces,
02--2-�-2.Olto 1 LP`f 1 War or Dates ) ilA3- /970
iie,Place of Death I Hospital, Institution or
Cilb Town or Village G $' Jet Ps i Street Address I�nS Fct 115 CiSP'}a 1
a Manner of Death � Natural Cause Accident Homicide Suicide Undetermined Pending
iy Circumstances Investigation
W Medical Certifier Name Title
1coon 1 IVozy) r M
Address 69
Certificate Filed ^� j DistrictNumber Register Number
Ci , own or Village 6,, IQY1S c 1� + �� O
urial I Date j Cemetery por Crematory
❑Entombment! v - 2-9 -2._()-2._()1 1 'YLQ- \ ;� e`,- e C-rme,vt-c c-j
Address
E 53,Cremation 1 kye erS'b0r�, N I 1 Z. F
Date 1 Place Removed
ri Removal
CO and/or C Address
; and/or Held
CO
Hold
a ; Date Point of
Q Transportation j Shipment
let by Common Destination
Carrier
Q Disinterment Date j Cemetery Address
Q Reinterment Date 1 Cemetery Address
Permit Issued to + f Registration Nu
Name of Funeral Home A'�, f 1vr IL M d fit
� J
Address Cl L 1\f/i rrrp Sr OBI 12,0
Name of Funeral Firm Making Disposition or to Whom
aRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2. /2_9 j 16 Registrar of Vital Statistics UO t&\_,1,,
Wr
(signs re)
District Number 560/ Place 6 (sirs Fa `, / p l J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Vi Date of Disposition 3/1/16 Place of Disposition _Pk. tr f'Icx..
(address)
tit
(section) (lot num (grave number)
Name of Sexton or Person in Char of Premises . ,r4, 4
(pl se print)
lt�E Signature Title (i7.104—Tbil
(over)
DOH-1555 (02/2004)