Reilly, Mark NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
` Name First Middle Last 11 Sex
Mra�1L Re M
fiti Date of Death II Age i If Veteran of U.S. Armed Forces,
iiii t\ \ ZLI 1 2-015 4 (QEc i War or Dates i 9(06- iQ/l,e
. Place of Death I Hospital, Institution or
City,�oyttz-br Village Ol.L \&P tic- l Street Address Lfl.Q C i i° Ave.
Manner of Death54 Natural Cause n Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
:'' Medical Certifier Name Title
�ai-r'i-G Ct f ev �1. 0
ii Address Z
Death Certificate Filed /+ District Numb j Register Num er
_< City, Town or Village 1 t/ S I fl 1
Date ( Cemetery or Crematory
n Burial i Z S ) 10)6 P;n e Vi cu C'r-e
Address
EY Cremation A b v Z
/ k
Date ` Place Removed
g❑Removal --_--,-_ 1 and/or Held -----^- -
and/or ; Address — {
a Hold0 ! Date . :;int of
an Transportation i _ Shipment
a by Common Destination
Carrier
0 Disinterment Date r Cemetery Address
Reinterment i Date Cemetery Address
Permit Issued to " Registration Number
Si Name of Funeral Home Baker �u,n-rai Home_ i Oil 3C
Address
11 11 L a:rail,cetc
a+. , 01,cLosb i r, l,ve.w LIo 1 eozi
Name of Funeral Firm Making Disposition or to Whom
.`. Remains are Shipped, If Other than Above
6. Address
I" 1
- <i Permission is hereby granted to dispose of the human remains described above as indicated.
ill Date Issued 1 (- o,5-DV(5 Registrar of Vital Statistics + ' -0,4--L c Q12,K
(signature)
it District Number av S'1 Place V c c.rl S t lJvc.,'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii Date of Disposition (1(ri A(- Place of Disposition \L1 1,..ow1._
2 (address)
w
CC (section) Atfot number) (grave number)
CName of Sexton or Person in Charge of Premises L hnsffrerH14-
Z (please print)
Signature Title /17fri/i at
(over)
DOH-1555 (9/98)