Dzik, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
"_ Name First iy Middle LI I Sex
ert-I 2._t573 6779/ ZikC FL-Ftt etcDate of Death / Age If Veteran of U.S. Armed Forces,
I b z( /lv 7 q War or Dates /J/4
1: Place Death Hos ital, Institution or
111
City Tow r Village 0, C -�S.� treet A re I M pA6-� /I1_[.S Pici t/�
CI Manner of Death®Natural Cause D A ident omicide 0 Suicide Undetermined n Pending
Circumstances Investigation
ill Medical Certifier Name Title
Address
1b I Crjef,y $1p.mRio
Death Certificate Filed District Number - Registar Number
City Tow n o Village t) ,.J S UY1/ 1 ( Lf
>_< 0 Burial Date Cemetery or rema o
{Entombment /0 l/ /2 y_ �O �.J t! �/0,-,__)
Address
'(Cremation & U 6t7/b1-. v i✓t✓�1 S Q
Date Pllace Removed7, ‘,47
Z Removal
and/or Held
and/or Address
t Hold
W.
0 Date Point of
DI Q Transportation Shipment
Q by Common Destination
Carrier
0 Disinterment Date Cemetery Address
li
El Reinterment Date Cemetery Address
Permit Issued to �--� Registration Number
Name of Funeral Home Vex t- );\es2�\ Hpfi \k. C 11 Q
Address
II Lea' e . a,e_aN1S i / N\k 12(6 0`I
sT Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
2- Address
U
Permission is hereby granted to dispose of the human ' s desc " ab indic ted.
H
Date Issued 10�._((� Registrar of Vital Statistics ��AO )(k„,
(signature)
District Number 1_ -7 Place �
<«< I certify that the remains of the decedent identified abov re disposed of in accord?
ccord with this permit on;
ILI Date of Disposition /pi 27)lb Place of Disposition
40 ✓ Crar.A„
1 2
(address)
U)
CC (section) ,` (lot number) (grave number)
Ci Name of Sexton or Person in Charge of Premises lhri;fr /' Sr�eotr�
44
2 (pi se print)
n
Signature �L Title feff Atria_
(over)
DOH-1555 (02/2004)