Poje Jr, Frank re . ,y,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Burial - Transit Permit
Name First Middle " . Last Sex
r72Aiiii< l-'c:J E ,fait y-'j
Date of Death /(5' Age If Veteran of U.S. Armed Forces,
A77 GG/ '� b� War or Dates
,. Place of Death Hospital, Institution or
Z City, Town or Village eVe4,%di Q46 J( Street Address Atli1Zckhk 7-4i (;c'tir"t it
It Manner of Death LrAl Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined 0 Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
C
Address
Death Certificate Filed District Num • RegisterNumber
City, Town or Village 5t.12 r _ 3
['Burial Date Cemetery or Crematory
❑Entombment `���� /b pi4� V f 4" rid
Address
&Cremation
Date Place Removed
Z Removal and/or Held
❑and/or Address
F= Hold
+ta
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home (5 6 W iotb 1.. f Of J,ky vd`�6
Address
.sc $4 rZ,et' i LA Htsa , 1\1,yi
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
1
In
fl` Permission is hereby granted to dispose of the human re - s described abov as indica d
Date Issued to dg r c Registrar of Vital Statistics , 0 a,
(si ature)
District Number Place LA3�� <_"./6oh f)- \a i
I certify that the remains of the decedent identified above were disposed of in accordance with this p- jl it on:
Z
LAI Date of Disposition /0 hi/c Place of Disposition .dine!--/ L t+'a f'+w-
L (address)
Ili
Ott
CC (section) (lojnumber) (grave number)
0
ti Name of Sexton or Person in Char a of Premises t-- ""'
I (plelase print)
til
Signature Title r1 utWa2
(over)
DOH-1555 (02/2004)