Spire, Michael NEW YORK STATE DEPARTMENT OF HEALTH "`- # 211 -
Vital Records Section Burial - Transit Permit
V.-Name First461dle Last Sex
_ r1.T_c_!1►O CL. T1�E R� S Pl y C_
.;± Da e of Death I S 17V-:,,LA
teran of U.S. Armed Forces,
ar or Dates
• • Place of Death ,. ``"' - Hospital, Institution or
City, Town or Village Q..,C C r-3 ,•-"2--"1 j Street Address 43 Q1--r_.,a1--- Q VI ..) /re-,
sManner of Death RNatural Cause ❑Accident El Homicide El Suicide nUndetermined D Pending
t Circumstances Investigation
Medical Certifier Name Title
0 f QV__. \Ac Fyvi A 0 wl
a Address
102 em-zillairA- C_,Lc IL)s FPL_L__s t`YL\ k�i5 D
<;;Ks Death Certificate Filed District Number / Register Number
I City,Town or Village �v Cc-�sc�� `Q\� j (J /
Date � I Cemetery or Crematory
El Burial L1 /06 (QZ) i S N t \)\ 0. NJ L_E iv, ATace---`\
Address \acizA
®Cremation Q.•)Aki_ tc11, `R`) Cj ,c,L IJ S F-jV i.z `' 1- 71
Date I Place Removed
Removal i and/or Held
and/or Address -- -----_� _-�--'
�' Hold
} Date _-- -------- 7-Point of
fki Q Transportation _ — Shipment
C1 by Common Destination
Carrier
Date Cemetery Address
: D Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
aName of Funeral Home Ha ayHa rd b, ZQker FGU1eral Horne_ 01130
gii Address // LCCfa.y t—C • , &i,(.C.CriSbu rc j i /UeW 90 )L 1 aCOL/
j Name of Funeral Firm Making Disposition or to Whom
"" Remains are Shipped, If Other than Above
Address
tZ
_ i
€: Permission is hereby granted to dispose of the human remains described above as indicated.
.E , I7-off "-cam,
Date Issued 4 f O l�0 I�' Registrar of Vital Statistics ,
(signature)
District Number 5 lJ 5
Place 0 01z Q(1Sv ij
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. �. Cri.--
ii
Date of Disposition K l 2l( I a� Place of Disposition Iu ..
M (address)
c (section) lot num r) (grave number)
0 Name of Sexton or Person in Charge of Premises "'r�/t ct+ i
(please print)
I'"
t. Signature 4Title r t? ^�-
(over)
DOH-1555 (9/98)