Hickey, Peter NEW YORK STATE DEPARTMENT OF HEALT4 i .11
Vital Records Section BUrla� - ransit rmit
Name First ID ,Oldie t Last./ Sex
Date of Death Age If Veteran of U.S.Armed Fo es,
���� esfrl
A of 6 `'� War or Dates
Z of Death Hospital, Institution or 1
own or Village -, z� ��r. Street Address Ph- +�--- }�
Ct r anner of DeathDia Natural C*seL_I Ac8%ent Homicide Suicide U letermin Pending
Medical Certifier
Circumstances Investigation
CI
res Addpail._ Title
Address} i CA
th Certificate Filed District Numb€�r ® Register Number
OTown or Village r./ h r. v
■Burial Date Cemetery or Crematory
Entombment Address r-
EiCremation nt e_1 s i IdG--- 7or'�
Date Place Removed
❑Removal and/or Held
.�. and/or Address
Hold
0 Date Point of
Di OTransportation Shipment
d by Common Destination
Carrier Cemetery Address
0 Disinterment
Date
Date Cemetery Address
0 Reinterment Registration Number
r- GoY
Permit Issued to c"a�--. -.-NA.et, H.me
Name of Funeral Hom�G`' Av e, {W/ I�$�� .
Address51,44AA.,..7
Name of Funeral Firm Matting Disposition or to Whom
ed, If Other than Above
Remy are Shipp
Addressid
es ib r • dicated
dispose of the human remain + ab°' .
is heret�y ranted to Q-�r,
6 Fermis- of Vital Statistics (signature)
j 5 aot&Registrar
Date
eteed 1r. /
Place _ ter'` s r�� � permit on:
per a Sy d above weref ispoSe' of in accordance with this
D+s�t Num � �edent identified re�g of the (address)
II ,t that the (1 mace of Disposition (grave number)
$��' t� (tot number)' of DisP � /!
r (Section) t Date ositi i print)
(Pt ase p
"'� Charge of Premtises W4
Person inTitle (over)
Name of SeX
Ui
t�or�Signature