Coryea, Fred NEW YORK STATE DEPARTMENT OF HEALTH 3
Vital Records Section Burial - Transit Permit
Name First C� Middle Last Sex
A ✓. C0/2Y
Date of Death ����r `� Age If Veteran of U.S. Armed Forces,
? War or Dates 4---�
Place of Death Hospital, Institution or
City, Town or Village e/.ems ,T�/t (Street ddress / �Sdv� d l A z.i 4O 2
Manner of Death r2f Natural Cause 0 Accident Di Homicide 0 Suicide El Undetermined n Pending
ill
Circumstances Investigation
tu Medical Certifier Name Title
O Ze e/0.44 V/Af / J A<4,
Address
��t ,c/l, /
Death Certificate Filed �/ District Number Register Number
/
. City, Town or Village '�s 5 60/ 39 8'
[IBurial Date D�o V20// Cemetery or Cremator
/�/Avg C /
❑Entombment Address
': Cremation 'e64 4-'A-yi N>' /2r0 V
Date Place Removed
❑
Removal and/or Held
and/or
Address E;;�
Hold
0 Date Point of
Transportation Shipment
GI by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
>: Permit Issued to ,� / / / Registration Number
Name of Funeral Home /2i4/A)A / .d. , // it�i '/ I.Pi- 0/130
Address // `,1ni`/ siceei 3 t//L
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address •
te
I
Permission is hereby ranted to dispose of the human remains des ib-d : .ov= -s in c .
Date Issued OF vg 2011 Registrar of Vital Statistics 1;
(signature)
District Number 40/ Place LaXfd ,l`J, /(iy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ui Date of Disposition 1-y-t t Place of Disposition Phu U•i+-i Cet"-et otiv`
(address)
w
t
I (section) (lot numberr (grave number)
• Name of Sexton or Perso in Charge of remises r,si — e.+.-iN"
2 (please print)
• Signature Title (n�iw►V}T6Q.,
g 7
(over)
DOH-1555 (02/2004)