Lescault, Daniel NEW YORK STATE DEPARTMENT OF HEALTH r 30
Vital Records Section Burial - Transit P rmit
Name First. Middle LastSex
��;LL Z s c L.-E- -R, ".le
Date of Death Age , If Veteran of U.S. Armed Forces,
(, 11 1).or L 7s War or Dates
} Place of Death/ Hospital, Institution or
Z City, Town ilia e --,r:A Z Street Address
ti„
a Manner of De Natural Cause ❑Accident 0 Homicide El Suicide ri Undetermined Ej Pending
Circumstances Investigation
W Medical Certifier N e � Title
1 L TV /
k ill Al
Address C L 1 )3 6 6
J �t.�� c.,t i �1r � 1.
Death Certificate Filed District N ber / Register Number
City, Town or Village 11 r' 'fSa ) 6,
Date Cemetery or Crematory
Burial 6 /IS' /),oty i.‘ev-.c ...- Cfc.'" a+
Address
Cremation 67,-,Lee A.5, r e -,, /.rK
ZDate i Place Removed
0- Removal and/or Held •
t- and/or Address
Hold
O Date Point of
C.
_Transportation Shipment
E by Common Destination
• Carrier
Disinterment Date Cemetery Address
—
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home � "SMom . e r...( L-1.>Me) ....Z._ 00 It'-`hf
Address /
Name of Funeral Firm Making Disposition or to Whom
L" Remains are Shipped, If Other than Above
Address
M
>
Permission is hereby granted to dispose of the human r ains scribed ov s ' icated.
Date Issued 6 /"i bon-- Registrar of Vital Statistics .t4't/
a re)^ /
District Number
�-1-c a\ Place C_... a!'; —i /v� .. %.(,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-- D 'I /'
W Date of Disposition 6IIs IR Place of Disposition '0++�Vuv `rvKitot w,
2 (address)
uJ
N
t2 (section) /Ij (IQt number) ( (grave number)
C) Name of Sexton or Person in Charge of Premises I A ri Syd r fIAK
ir
Z (please print)
W Signature /44-* Title 0101111Yrdg,
DOH-1555 (10/89) p. 1 of 2 VS-61