Barrows, Paul it qr
NEW YORK STATE DEPARTMENT OF HEALTH /
Vital Records Section Burial - Transit Permit
Name First _ Middle Last Sex
+Au I F Zar raiNs Ma le
Date of Death Age T If Veteran of U.S. Armed Forces,
1- 2-61 - 2 C)Ro 31 ! War or Dates
I Place of Death / � , ,�1,LL-. ! Hospital, Institution or, I
3 City, ow or Village LC,RK L. 4- Street Address Lc (�''►) IC /5 Rd ,
p Manner of Death V Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined Pending
in Circumstances Investigation
O.
Medical Certifier Name Title
(' Address
C , t1 , ,ti
Death Certificate Flint District Number Register Number
ow City, or Village Lnl:K L Ztr-i' 5(0 56,
': 0 Burial Datemete7 or Cremj�tory
Z - (� 4-1 ne V/1ei.l) �_ e(Yla/0 ,['Entombment Address
gCremation us k.iu h ut.r/j, NY
...
Date ' Pint- Remove
Z n Removal and/or Held
_ and/or Address
F Hold
CA
0 Date Point of
❑Transportation ; Shipment
0 by Common Destination
Carrier
Q Disinterment Date I Cemetery Address
j Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homer L,Le,� -si-yZ.n I �/ Inc__ ()au'
Address /
' Mitch is Lj _k_g_ I i.(l-Q,/71 A,y /20-(0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,2- Address
CC
ill
eL
Permission is hereby granted to dispose of the human emirins descri above i icated.
Date Issued )-2.9-/(p Registrar of Vital Statistics �-
�/ (si ature)
District Number 5(05 % Place I�>wn c-.. b L r-ya A,f
l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k ®
Iu Date of Disposition 2/1//b Place of Disposition �'nt Ota.J erorn}orhAi_
(address)
in
U)
iM (section) /1/(Lot number) (grave number)
O Name of Sexton or Person in Char of Premises ( �►i o )-r Soy' +
a (plelase print)
, Signature Title V
(over)
DOH-1555 (02/2004)