Moston, Oleg . NEW YORK STATE DEPARTMENT OF HEALTH )
Vital Records Section Burial - Transit Permit
Name First / Middle Last / Sex
Date of Dea h / Age If Veteran of U.S. Armed Forces, �-' /
J.,.?_i ,9- War or Dates % /4
--- Place of De th Hospital, Institution or
W City, Town or Village _. -r �A- Street Address .,_t'S/ ,%>1E y
Ip Manner of Death Natural Cau e ccident 0 Homicide 0 Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name .�� Title
P. � Gh'7s6f ��fi4-/�bre 6,4 0,1 b
Address ,J/ v ii`
Death Certificate Filed District Number Register Number
City, Town or Village �.,.1r G;" //, yr°
['Burial Date / Cemetery or Crematory/�
❑Entombment // ' / 7/Ak vie,-Li /"es-m1
Address
iii!igCremation /
Date Place Removed
Z 0 Removal and/or Held
and/or
H Address
VI Hold
O Date Point of
t Transportation�❑ P Shipment
a by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �— Registration Number
Name of Funeral Home /tri2f)64v j-'��`7C/,� i jiyy.� Ol r�
Address �t /�/
Name of Funera/F°m MakingDisposition i �r� / i; - 76i
p n or to Whom �ti��
Remains are Shipped, If Other than Above ,..-t(/-
2 Addressit ' Y/4
ILI
rZ` Permission is hereby granted to dispose of the human r in d riber as indi ated.
Date Issued j' �� Registrar of Vital Statistics
�' (signature)
District Number Vp / Place <�-i„�% JAe /�L� _ y•
-_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition 3 I, i 7Ol0Place of Disposition 4 ,,Of C I,) C e"vItiortu^
2 (address)
to
tC (section
)) l/ (lot nytnber) (grave number)
ti Name of Sexton or Pelson in Charg of Premises lift syk-' eipiti
z (please print)
til
Signature Title atithel i oft
H.
—
(over)
DOH-1555 (02/2004)