Bozak, Martin 4NEW YORK STATE DEPARTMENT OF HEALTH r . �tf if .K$
Vital Records Section Burial - Transit Permit
Name Firs Middle / L Sex /,,
/�/C(7'7 'h �J��l /� 19�Q2 /1lf L� '
Date o Death Age If Veteran of U.S. Armed Forces, _
71,zat/ �i 2 CVO j War or Dates /f�',3 cj /, 5 -
1- Place o peath Hospital, Institution or
W City, o nor Village 4yr duke- Street Address
ilk Manner of Death5l"e"tur Cause Accident Homicide E Suicide Undetermined Pending
ILI � Circumstances Investigation
wMedical Certifier Name 12 l/ Q /2Ti
/.Add ss //
» Death C ficate Filed District Number Register Number
City ow r Village9 Aj/(--)7.1 . am( C9�S-- -
❑Burial Date .or Cremato �^
/�, ��1 ee7//-�/4 ec e/x/e )Ti ,,J
❑Entombment Address `
;;'�Eremation /� %�`�s ��
_// .)-,,�
Date Plac emoved
Z❑Removal an /or Held
and/or Address
H Hold
CO
O. Date ' Point of
ti El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-
Permit Issued to Registration Number
Name of Funeral Home/1/r --1. "--;-7,(_ . 0// 7
Address
3 5_ �/ �iP 3 -- 2 / ____��7/oz ei�
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
C
Ili
Permission is hereby granted to dispose of the human re -ns described above as indicated.
Date Issued / Registrar of Vital Statistics v)(/
Vieti
To
(signature)
District Number A Q�e;, Place X c
J
I certify that the remains of the decedent identi ►ed above were disposed of in accordance with this permit on:
la Date of Disposition R/7- (, Place of Disposition /i,Q ( ;mkt) I.-re.-ram G TG��
2 (address)
Ill!
ta
III (section) 1 t number) (grave number)
Ct
Name of Sexton P son i har a of Pre ' es �.J c. 1 i a✓' &a 04- VA e
(please print)
til Signature Title /✓t
(over)
DOH-1555 (02/2004)