Miner, Sr. Eugene --e r Suti
NEW YORK STATE DEPARTMENT OF HEAIIH iii
Vital Records Section A ••lik Burial - Transit Permit
Name First #— Middle Last Sex
12 �� li . M ,4e-r s� (AA.a,_
Date of Death Age If Veteran of U.S. Armed Forces,
to/ / Aot( .73 War or Dates —
Place of Death / Hospital, Institution or
iii:Z cip own or Village C s -U5 Street Address
0 .nner of Death®Natural Cause El Accident ❑Homicide ❑Suicide Li Undetermined ❑Pending
it/ Circumstances Investigation
;l Medical Certifier Nam. , Title
lV i alAeL te-LL Vti ..D .
Addre
D rim,Imo.¢r Qve- , 6 ' —. N.Y_, ' t8a,.
iigii P-- h Certificate Filed District Number �_G Register Number
C9
,41
own or Village L e.,S FKt,(y' (
urial Date Cemetery or Crematory
1 / it / a,tt r`ne V,'e_�.. Cm........46
0 DEntombment Addressr L
[]Cremation �Cv....c��C, b,.r / .10e....-) 'iveyC
Date Place Removed
} ❑
Removal and/or Held
� and/or Address
til i Hold
U Date Point of
t' El Transportation Shipment
Lit by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date • Cemetery Address
Oi Permit Issued to Registration Number
Name of Funeral Home ` .itSMD re 1 ,..4,ei-t /-h,,, - Do Lid re
Iiii Address / f� /
7 5U1errA,- AVc l ,r.A.)-1,. ` P. I y
I f,.'i .1.-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
I .
Permission is hereby granted to dispose of the human main ascribed a ve
as Indic
Date Issued J)/ it/azi( Registrar of Vital Statistics • . A oZ-€
(signature)
District Number 3-6 Os_ Place
1 I certify that the remains of the decedent identified above were disposed of in accordance wit this permit on:
Ili Date of Disposition (d-.tl_X t( Place of Disposition 'Pineki e,0 r,,,,Ac- 04%
(address)
III
0
cc (section) (lot number) (grave number)
ci h�
Name of Sexton or Person in Charge of Premises 1 + 4t+--1 "ellQ.
-------7
�� (please print)
lit Signature Title C` -°
(over)
DOH-1555 (02/2004)