Tassely Sr, Raymond NEW YORK STATE DEPARTMENT OF HEALTH-' `' Or
Vital Records Section Burial - Transit Permit
Name Firs Middle Last Sex
N-Ai`'1 O tJ7 A
1 IS S E L`-1 S - M
Date of Death Age c� if Veteran of U.S.Armed Forces,
a `1 b i i O 1 War or Dates
z Place of Death --� Hospital, Institution or
City Town o ii 1 (,>(Z. »I Q i LL Street Address k 't A N Kt v t R Q E N AQi L iTATt oti
�, Manner of Death
y ❑ ❑ ❑ ❑Undetermined ❑Pending
�� Natural Cause Accident Homicide Suicide
Circumstances Investigation
x•
Medical Certifier Nam Title
r- k}-1OMiLS 41-1Z0(2-A 6 0
Address
11 016,13 I.5a 37 GR_A N\) , L isS • 1`a_$' 32
Death Certificate Filed District Number Register Number
V. 7
. City,Town or Village (:j � L
r, v 1
Date , Cemetery orCrematory❑Burial la l tNc f toJ l: r A 1 0(t•(
Address _®Cremation Address,
1�E ZLA‘` D V L C N5 li`_`l h„r
❑Removal Date Place Removed 1
and/or and/or Held
Address
ri Hold
d.
• Date Point of
❑Transportation _ Shipment
" by Common Destination
Carrier
:.:::0 Disinterment Date Cemetery Address
' ❑Renterment Date Cemetery Address
r Permit Issued to ` �2_ Registration Number
Name of Funeral Home A-fa /la.rd /), 3 cker Funeral home_
e Address �� 01130
LaEcuiate . , bcA.e.ensbury,AJe wJor-k I O/
i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he ranted
Y to di space of the human rem s abo indicted.
Date Issued 0 /� /,� Registrar of Vital Statistics
W;h (signature)
District Number 5/ `�f Place 62- P--•
I certify that the remains of the decedent identified above we disposed of in accordance with this permit on:
'' Date of Disposition 2,1 tof i S Place of Disposition g,0._...) 6 f ,-
(address)
it)
• (section) A (lot number) (grave number)
•Q1 Name of Sexton or Person in Charge of Premises ,
34411—
r (please print)
:•. Signature n Title ( t y^
(over)
DOH-1555 (9/98)
-