Sukala, Eric NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . y f y Burial - Transit Permit
Name First Middle Last Sex
E r i c. L SuKraIci. L4a(e.
Date of Death Age If Veteran of U.S. Armed Forces,
7 -LCI -,2_0 /S 4(p War or Dates NA)
1— Place of Death Hospital, Institutio r L I L
two, a G I e ns Fa I I S Street Address 0�e,i5 f-Cr 1 Is f I uS !1 �t
i 'anner of Death Natural Cause ['Accident ❑Homicide ❑Suicide ❑Undetermined �❑Pending
W Circumstances Investigation
ui Medical Certifier Name /� Title
O Tmo'(�y Murpky Caror(
Address
C 1 c4'15 1--CC I Is
Death Certificate Filed� District Number Register Number,
CCitvlTown or Village 0lens Fa_( I5 50D1 37q
❑Burial Date j Cemetery or Cremato
❑Entombment O 11 31 ` ZO(J -P) ne VI e �, Cif rna-hp/�L�
Address
Cremation a G1 ecns b u ��.,{
Date J Pla e Removed
g ❑Removal and/or Held
and/or Address
I= Hold
f/
O Date Point of
F'0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-Bre(,Lfir -jLy)Q�(2( I 1-'j`Q( e, i n t; Wa I l
Address (A-11- C,h u.rC h $ ( , L A 1 J Aly
l 'gc he
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2 Address
1X
ILt
Permission is hereby granted to dispose of the human remains des ribe abo e as ' icated.
Date Issued 07 3/ 2o/�Registrar of Vital Statistics
/ (signat re)
District Number j(p 0 I Place Cl--y Q G 1 cos T//5
'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1=-
Z
Ili Date of Disposition '2-3/-tS Place of Disposition ` one (a e�) Ct' 'ci c:74 or itivi
2 (address)
Lu
VI
CC
(sectio (lot number) (grave number)
0
D Name of Sexton or Person in Charge f Premises 1'41 aik`r r�reU-
L 7 4
'-V v (Please print)
Signature jk Title ermma4 P
(over)
DOH-1555 (02/2004)