Martin Harold i ,, -E(----7-Art., D -pa)--1-- 4 "717
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir t • Middle Last Sex
k-1't is . eLl4�, .4 DArme � .�
iiiI Date of De h Age e If Veteran of U.S. d Forces,
Iiii (n 11,1 9
(v it f j' War or Dates
R. Place of Death Hospital, Institution or
ii City, Town or Village Street Address
t Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ul Circumstances Investigation
tii Medical Certifiername Title
Address `
52 inti --ge.$fkee7 Jut/6/0l) �aL1LJv r� 4,,A /2a,- ,�
D th Certificate Filed,,_, District N/Jumber Register Number
ilini it own or Village 3P&N _ 3f;,4j(n j "1 51j
❑Burial Date 41-Wit/
Ce tery or Crematory
❑Entombment i,1)Li J t\: .J CA,ry ii
Address
j' < ff Cremation C�, u ,.vb Q�-} / toy
Date Place Removed
Z Removal and/or Held
RI—land/or Address
H Hold
fl) `-
Date Point of
i0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
sii.❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
i Name of Funeral Home Nit9Q-S fi,vt1A1_, div,e4.- lA,(2_, map,/
Addresws� p� { n
��VZ J M L O )24-)4 , K-til JtA
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Name of Funeral Firm MakingDisposition o�Whom14 �'
p
Remains.are Shipped, If Other than Above
Address
irk ---
L Permission is he eby granted to dispose of the human rem�i.p sc 'bed Vve s indica ed.
Date Issued %p 'j f� Registrar of Vital Statistics L_ ,
/ si nature
( 9 )
la District Number q50( Place '3A,li �� yA �5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r.ilt Date of Disposition /o1l$/i� Place of Disposition fu lew Cri me
', (address)
LU
It (section) #flot number,. (grave number)
Name of Sexton or Person in Charge of Premises fits friil41
z lease print)
11 Signature CI Title Grille At
(over)
DOH-1555 (02/2004)