Sefren Jr, John • /6 )
- NEW+YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i -
ra Name First Middle Last J{ Sex
qt Jbr�, .k�• Sear er 1'l
Date of Death 1 Age i If Veteran of U.S. Armed Forces,
\DI C6) 15 j t 9 8 i War or Dates 16110-1- l g 7 I
14 Place of Death )� ! Hospital, Institution or dtP,tj
Igor �
2 City, Village 1 i s),i ) 1 Street Address )O$ Y Qu n ,
Manner of Deathteu Natural ause Accident Homicide Suicidela Undetermined ing
Circumstances Investigation
tt Medical Certifier Name Title
R��r Sr;b v' Coro-nef
`w; Address S5 beC
W Road l�Y\, Y161�, ) iql ) 2-1
iiii Death Certificate Filed . District Number, 1 Register Number
>< City o • •r Village h;n s y E3'76 ! 1 S
Date i Cemetery or Crematory
::: 1--1 Burial \b��., Z01 Pine. v,ems Cernat4-o
- Address
®Cremation' ‘)1/4Q.
Date Place Removed2 El
-1
2 Removal ': and/orHeld
n and/or Address -- - - _
Hold
0 i Date --- -- -- P,;;nt of
C Transportation - j Shipment
ESby Common Destination
Carrier !�
': Disinterment Date Cemetery Address
::.< Q Reinterment Date Cemetery Address
< Permit Issued to �a ex I Registration Number
Name of Funeral Home �u ecQ 1 \o'M C- (l O\\3 O
Address 1\ Laca e S e2-4- Q v,eensbikr,i , N`( 1 ?_got-i ,.
Name of Funeral Firm Making Disposition or to Whom
f=" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma s described above as indicated.
Date Issued t 8 -'7, d Q/S Registrar of Vital Statistics •
(signature)
s` District Number5% a Place In r,,- •
-c ` ,U 2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii Date of Disposition 10 RII'S Place of Disposition R..,ik./ Cwo<lor,v.--
2 (address)
11.1
(section) /f lot number) - (grave number)
n Name of Sexton or Person in Char a of Premises oGil ,Sr«
z /I/ (please print) +►
94 Signature U(• Title VARIL
(over)
DOH-1555 (9/98)