Magner, Shane NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
':' Name First ti Middle Last ( Sex
` han e, rR,c 1 s Macnec I a,(-e
. : Date of Death Age 1 If Veteran of U. Armed Forces,
(D I `{ ( 2O j 1 1 I War or Dates N.)0
Place of Death /�, Hospital, Institution or , , )�� j�'`,s e�z-7)o-) cti
City, Town or Village ulUt'�(1SbuLr Street Address Eu''i--L61�p v-� 4 0 d- /KAU &.s,-.-
-0 Manner of Death❑Natural Cause El Accident n Homicide ( Suicide Undetermined n Pending
"� Circumstances Investigation
jj Medical Certifier Name Title
P 4 ) c S 1/c 'tL /4'L)
Addresss---0. 8,,a_v, s),_, t„) ,,,-4,,,,,,, /t
i--y
Death icate Filed District Number Register Number
City,lownjcir Village 0 0-1,-t3--,,,.ra a 5 kO 5 � 131
❑Burial- _ Date �� /...c'
l /760
� Cemetery rematory 1)Entombment 1 , ' e��
Address 'II
:: { mation C t1el / V ,n C< Uy2'.J a 0 r /07
Date ` Place Removed f
kC Removal j and/or Held
2 and/or Address
�� Hold
Date Point of
E.❑Transportation Shipment
by Common I Destination
Carrier i
;; Disinterment Date Cemetery Address
Reinterment I Date 1 Cemetery Address
i
>: Permit Issued to Registration Number
Name of Funeral Home &A �� � 1 tcc- \ f'10�1 C' 1 1 ? 0
Address
Name of Funeral Firm Making Disposition or to Whom
i4 Remains are Shipped, If Other than Above
• Address
ft
la
f;' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (D-a V-a0)L, Registrar of Vital Statistics R A-k-- '- .-A �et----
(signature)
District Number 5 us i Place e en S{vV/
j
.i,:.-''':'-:' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition /i 1 i j 16 Place of Disposition .4700 o.,-) Crt-mc.tryt.,
2 (address)
la
CC (section) ist(lot number) (grave number)
0.
tl Name of Sexton or Person in Charge of Premises a A i Scn(0"
(pl ase print)
14 Signature et Title ti /t1 ..
(over)
-
DOH-1555 (02/2004)