Lynn, Stephen tr
NEW YORK STATE DEPARTMENT OF HEALTH* � '
M
Vital Records Section Burial - Transit Permit
N.
Name First Middle Last Sex
-SEE k -3FK A RK ___ M ALE
Date of Death Age/ If Veteran of U.S. Arme Forces,
fl , ,1 4,) c.0 1 a- 6- �. War or Dates O
f- lace of Death Hospital, Institution or
Z City, Tewnef-V+4kge g-LC ¶ Li Street Address � LL o5P1 Ti{L
Manner of Death 0 Natural Cause 0 Accident Ei Homicide 0 Suicide El Undetermined ri❑Pending
W Circumstances Investigation
tu Medical Certifier Name Title
l AQEeL.- Pt, G ILL AR% AY\5?
Address
)o - PPtR-k , i, ) -CEr.J S =A- SON)1\ 1 a_g 01
Death Certificate Filed �,,-� Distract Number RegistnNNmber
City, er-Village (D a s sFALL,c ,S60 1
❑Burial Date
ew� r� ,1t,remato& OV\A%
,.;:.: ['Entombment AA VI` a�) �' 'TieNE V ELc�
Address
Cremation 1_ :.a 1U f�kEiZ ���� �U E ,�7St�(A1 '1'1
Date Place Removed
0 Removal and/or Held
and/or Address
U) Hold
0 Date Point of
N❑Transportation Shipment
Q by Common Destination
Carrier
0
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address •
Permit Issued to Registration Number
Name of Funeral Home -I p,. ? p v, cft RI E) 1 Ijoc., Q I to c
Address
9 0 —0 NTCAc -► LA-€ C-6O�C-c.) IN 1 a'K -.s-
Name of Funeral Firm Making Disposition or to VV11om
I„- Remains are Shipped, If Other than Above
2. Address
C
W
eL Permission is hereby granted to dispose of the human remains d scri ed ove i icated.
il Date Issued . ;t. Io Registrar of Vital Statistics / 0z.
��0.-.---:OBI
(signature)
District Number ,s--601 Place
certify that the remains of the decedent identified above were disposed in accordance with this permit on:
ill Date of Disposition (//c At Place of Disposition ek‘V 4." Crvarf or,,,.._
2 (address)
L
CA
CC (section) (lot nu' r) (grave number)
ct Name of Sexton or Person in Charge Premises /L.r. v32 I (please print)
tti
Signature1 Tit
le �� n1l 4'
0-/\
(over)
DOH-1555 (02/2004)