LeForte, George NEW YORK STATE DEPARTMENT OF HEALTH , Tr11
Vital Records Section Burial - 1 nsit Permit
i Name First --�- Middle Last Sex /
�7?-0,v to [/J%,41 ZeJY� %/P�
Date of Death �/ Age If Veteran of U.S. Armed Foes,
II 03. -07�-aQ J 62c War or Dates /V0
Place of Death Hospital, Institution or Z Cit wr�r Village i ieem,4 Vt`' Street Address P7C;C0Y/474-iC dJr.iv
al
ci Manner of Death Natural Cause0-Accident 0 Homicide n Suicide ❑ Undetermined IT Pending
Circumstances Investigation
1 Medical Certifier Name Title
PI / �-z Y J� //C> 7� G Yj /d f
Address ,` / /?U /
Death Certificate Filed Di ict Number / Regiit r Number
»> Cityev�i'�r Village (pul ee r�S „r'
// Date Cemetery or Crematory /.
❑Burial 03 - /z Ah 6. �',P V✓ �YG.�,Jl.�
Address / �/f�
Pr-Cremationiii 6/4ci iP.� "000e �t teri s J� / //ra 1
Date Place Removed
F❑Removal 1 and/or Held
and/or Address
1 Hold
0 Date Point of
03 ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Q ie_,./' Registration Number
ii!iig Name of Funeral Home / 7 . a � 0//3(U
>� Address j/Lr�.�� J c�� are415- 11//'/P ���1��e l/e, , yf
>;>I Name of Funeral Firm king Disposition or to Whom
14
Remains are Shipped, If Other than Above
Address
Mi Permission is hereby granted to dispose of the human m ins described above as indicated.
Date Issuecrj)7(<s (�1 ri
Registrar of Vital Statistics r � '� `-'t -06 Iv.
(sign re)
P. District Numbe6C Place 1 a t o . 1LR-.Q--1„. a a.
I certify that the remains of the decedent identified above were disposed of in accorda fir th this permit on:
Date of Disposition 3-1"1-'t Place of Disposition -Fr-+VccW tv6`id``
(address)
U.'
N
CC (section) (rt nu ber) (grave number)
GName of Sexton or Person in Charge of remises ss A1if
(please print)
I! Signature /4L, Title Cti(M1C4(..
(over)
DOH-1555 (9/98)