LeBlanc, Normand I, .'N # 6g1(..
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First NC)food Middle Jo52 Last I o nC Sex A/\
Le
Date of Death Age l If Veteran bf U.S.Armed Forces, N lc)
20/2-0 lip I -]- L War or Dates 1
Place of Death I Hospital, Institution or ^
own or Villa e e 1Vs 1 Street Address Csle \,S "� --G 1
Manner of Death , Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W "� ® Circumstances �Investigation
ttu Medical Certifier Name Title
a Pi(1-0"\ASIA) \4-n,CILYSSY) A -0-tv\c i a qy\-c.,144
Address
i 12g54c
jillestO Certificate Filed t District Number Registe Num r / /p
Ci own or Village -�eY� �?113
� 5 ��j T i�t�C
_- j Date C-emet or-Crematory
❑Burial I C�� ally 2 O 1 C� ►Q V i e 1,J mai-or
❑Entombment) / �)
Address '
al.Cremation c O.V(S2!,„..- c4 i 1 .Q e .-r\S2 O 1 . Ail 12 '1S 4
Date Place Removed
®Removal , and/or Held
and/or I Address
09
5Hold a
Date Point of
42*❑Transportation ! Shipment
d by Common Destination
Carrier
r-i
Disinterment 1 Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Home �I1k. i U�,� l/Qn/7 C 1 /3 (D
Address '
I 1. s OsCre SIT-. Q 0 --r-5Q (A4--7 /� lz a ?'
Name of Funeral Firm Making Di-••sition or to Whom I
Remains are Shipped, If Other than Above
S Address
I
1 Permission is-hereby granted to dikpose of the human remains de rr' ed a vs iln Tested.
Date Issued 0 e /20/6 Registrar of Vital Statistics `/
(signature)
District Number 60/ Place 'lam _44 ,L>
i,... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� Date of Disposition 711(0, Place of Disposition 'f Jj t,,. ( of rs..
U (address)
Cl)
(section) 4 (lot number) (grave number)
Name of Sexton or Person in Charge of Premises <�r=T rr44t{r•f
Tease print)
iil Signature ,�� Title 01-f MIRK-
(over)
DOH-1555 (02/2004)