Lewchishen, Stephen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
la. Name First s\eeMiddle Last Sex `
iiiig Date of Death i Age ( If Veteran of U.S. Armed Forces.
O\ 110 1 Z.p1 Q ! C8'J I War or Dates U.r> nouW1
Place of Death I Hospital. Institution or
:if- )/Cit ow r Village ,..,�_Q�S�a. � 1 Street Address 5 Eve`�reer> AJ e s 'A 9�
Manner of Death
,Natural Cause Accid nt 0 Homicide 0 Suicide fl Undetermined ri❑Pending
ILI Circumstances Investigation
all
Medical Certifier Name Title
ti D1^ o.s �er>r>e 4- '\--)<�
Address
-
�y '6coe -d Sk i G wns �c \\S, 1�1\ ►moo!
` Death Certificate Filed 1 D- ' - t r - I Reg star \lumber
Cit , ow r Village C Q'c>S'c .c i (Q3 I.
Date 1 Cemetery or 1Crematory
Burial t C�\ 1 Z 1 aO\LQ I ir\L V i €3 C)(&C11C 1
Address -
�Cremation l 1 \ 2 -t
Date Plade Removed
-Removal I and/or Held
-'and/or I Address
Hold
0 ' Date _ Point of
n Transportation .i Shipment
by Common Destination - - •
Carrier
Disinterment Date i Cemetery Address
Reinterment Date ; Cemetery Address
- - . -
igi Permit Issued to _ i Registration Number
Name of Funeral Home _ 1?L r,,.. !v'1v % 1-"'-Y' I 01,130
Address
i L i - CT1 ; s t�i �s J..; 0 i2.,� L -/ d-` y r' I-L
Name of Funeral Firm Making Disposition or to Whom .--/ ' / -
Remains are Shipped. If Other than Above `Lj
Address -
iril Permission is hereby granted to dispose of the human rerrlains described abo ie as ipdicated.
<> Date Issued 0 11 GOI(Q Registrar of Vital Statistics . �_- „ ✓A__,...,
wk
(signse)
...... ��� Place / 0 �.�
District Numbe
I certify that the remains of the decedent identified above were disposed of in a ordance with this permit on:
Date of Disposition f /iyr/b Place of Disposition �(„ti,w� f ,fca la--
2 (address)
ul -- -
U)
1E (section) /pot numbe� (grave number) -
Name of Sexton or Person-in Charge of Premises •
OrsiL cs+gi
i/7�� (please print)
41 Signature 4'l _�� Title / tilliC
- (over)
DOH-1555 (9/98)