Manchin, Matthew ' -SX
NEW YORK STATE DEPARTMENT OF HEALTH4
Vital Records Section ` -" Burial - Transit Permit
Name ,,First Middle Last Sex/��' �
n A 60 Ls Aid c%�
Date of Death Age If Veteran U.S. Armed 6Forges
` --- Q op- 9-g/s� ,_� 4)6 War or Dates
j.: Place of Death Hospital, Institution or ;�,j�°
City, Town or Village 5Cjrae� Street Address '2I�n(,iti93 /�- -
Manner of Death❑Natural Cause 0 Accident Homicide Suicide Urfdetermined WrPending
Circumstances Investigation
tu Medical Certifier ame /� � � Title
11 Fr?IDCJ s v S
Po � 'IG�ddresS
. A A,t ----
Death Certificate Filed District Number���� Register1�Number
3C4
��City, Town or Village //
❑Burial Date C etery or Crematory
`Q - Cf -�ol� N e ui'eo el^e�/►l e Uy
Entombment Address aa �
::;::Cremation Q) j� A vvy /v- r
Date /Place Removed
Z Removal and/or Held
0 ❑M="' and/Holdor Address
tip
0 Date Point of
Os Q Transportation Shipment
G by Common Destination
Ez Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home AhL A as f roue i ( tia- �--(
Address l
Name of Funeral Firm Making Disposition or to Whom
J.E Remains are Shipped, If Other than Above
Address
cr
w
Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued(y-Qa"-o2OLS'Registrar of Vital Statistics (1-44,. 7,t 4,4.Q
_ (signature)
District Number `53 Place `0'07- r �✓' ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILiI Date of Disposition q. ..tS Place of Disposition Rile,';e,,i Ct`-c"444r t'j,vrt
(address)
COili
CC (section) I(lot number) (grave number)
bName of Sexton or Person in Charge of Premises t ►vlet hi y.e lC-
Z -------<-4 (please print)
Signature 44-�,.�... Title Crc Mk4®`7Peed'
(over)
DOH-1555 (02/2004)