Perez, Benito i 11 Lt( '-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Se
f� ,
e.J i i- &'12-C�Z /78-e.,&r-
Date of Death Age If Veteran of U.S. Armed Follies,,
PI/0 / )/ / ' 3 War or Dates 4/es
Place of D-ath Hospi , Institutiog r ff j
City own o Village a V AS(S Street cutress Ti�ou..IT lc7 T7,/ ice,
04
ct Manner of Deatt atural Cause ❑Ac - t n Homicide n Suicide ❑Undetermined ❑Pending
1 Circumstances Investigation
ta Medical Certifier Name Title J .1
A0 SL ,d �c� Loi= l lL)
Address
61'Z.- Cil u ktA) c;4. Lg.-3 6-- 62? UVW->•-r-S a Death 'ficate Filed Drict Number _ Re - ter Num r
City Tow r Village '�3 Q• -
❑Burial Date /1/
Cemetery Crematory
ie-Pbc U/61-3
['Entombment Address
r.emation U)g-2CL-N-_, Q ,-43 a virLo
Date Place Removed
ili0 Removal and/or Held
and/or Address
i= Hold
f
0 Date Point of
Transportation Shipment
ct by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home G,/nar 8 aer Vune r of kiory-+tt- 0 1 1 30
Address `1 L akky Q H e- SA. , Q ueen s\ouu v , Ni e v`i Yuri Yn?O i-A
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,2 Address
1r
ILL=!
11
Permission is hereby granted to dispose of the human re ains described ;j••ye as indicated.
Date Issued Q�-I - 2•0ti Registrar of Vital Statistics 7/7 -
/� (si101
:�ature)
District Number 5��� Place 0._u__a..,, :„\...._1 �'ct �
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition $-11-i I Place of Disposition i sinA ll w Cry iot 60w
(address)
141
CC (section) ` - (lot number) (grave number)
1 Name of Sexton or Person in Charge of remises L �i 03N 14 r ' .m&
z: dflyk (frt „ ,e
ease print)
Signature _ T tle
(over)
DOH-1555 (02/2004)