Siedlecki, Heather NEW YORK STATE DEPARTMENT OF HEALTI-1 4 Z cy
Vital Records Section t Burial - Transit Permit
Name First ,Middl Last Sex
EAT✓I Z .1FPLb2k/
Date of Death ) Age If Veteran of U.S. Armed Forces,
00 Mg l 2 /l 5 War or Dates
ig Place of Death Hospital, Institution or •
City own •r Village I-64,15 Street Address 35 ie-,5` C wA`-t
!... Manners of Death ENatural Cause El Accident Homicide 0 Suicide 0 Undetermined Pending
.41 Circumstances Investigation
Medical Certifier Na Title
.4 T. g PN1cf JD
Address
�' � k STG/ A-,/37owni , 1
Death Certificate Filed District Number Register Number
€ City110 or Village L�,c W✓5
Date❑Burial / / VP ?emeterYorCrematorYp ,E. I/ygW CrEMA-rd2-(-j
Addres
[Cremation r ifF.E1 Sj.3weij / N`(
Date Place Removed
6 ri Removal and/or Held
N and/or Address
Hold
Q Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiii Permit Issued to Registration Number
` ' Name of Funeral Home JJWLJE '> RAN L HHQN,cj /A)C- oozog
?i.
; Address
21-1 Cf4vtiZa4 ST i Po Box coo , L4 L(4Z R4i ivy
Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
aAddress
Permission is hereby granted to dispose of the huma remains descri ove as indicated.
gig Date Issued a--7,-Z4 /1 Registrar of Vital Statistics
signature)
iiiii District Number /S75-4. Place L CA./ <`5
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F /�
IT! of Disposition (.y l31 Place of Disposition Pa)leJ CrfAKtur ti,
X (address)
LIJ
(/)
C (section) (lot umber) (grave number)
dName of Sexton or Pe n in Charge of remises At s-4 0 latt-
z 1 (please print)
PJ Signature Title (C. Rrltra/C
-
(over)
DOH-1555 (9/98)