Lyons, Alan NEW YORK STATE DEPARTMENT OF HEALTH 41 I 1 b
Vital Records Section Burial - Transit Permit
t Name First Middle Last • Sex
I\1_A.1 Sow ►:,,.-\ Leo 13 s .. tlY\
Date of Death _ # Age ~� If Veteran of U.S.Armed Forces,
/ L I. 1 t- War or Dates '\ck``k 5 el Lk aj '
1.- Place of Death Hospital, Institution or
City, T�11age (Ui ti s rd L- Street Address L�>- s V ALs--S I CIIALL
IL:W
W Manner of Death® l__1 Natural Cause Accident 0 Homicide El Suicide 0 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title •
1 S� 2.4.N� c CZA►tiesic..1 --\ 6
Address
too ARy� Si- (, L1-1,5 PA j ...sti, v -g-Z A
Death Certificate Filed District Number Register Numbe
City,C.ivwn ut Village) ( LEt�S '�ALLS I t)1 IC I
1❑Burial Date �}�ry mete or Crematory
�� / CJ�V 1 5 t 1 IJ l i;,-3 C.,(�EM A l o R.`-1
0 Entombment Address
®Cremation C;1-v ek R C_D .mac COS 1s1/432`-k, 1J`-i k a%out-
Date ! Place Removed
Removal
2 and/or Held •
a and/or
I— Address
to Hold
0 . Date Point of
!A El Transportation j Shipment
da by Common Destination
Carrier
a Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
� I
Permit Issued to Registration Number
Name of Funeral Home H ul nGir 8 _ . k€r F x c r t ;n . C \i 3 d
Address 11 Lanye -He_ S�. , &ucf"C.nSbury , 1,0 e v,.� 04-k_. 12 Si0t
3
' Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
NJ Address
It
LE1
tL Permission is hereby granted to dispose of the human emains • -scribed ove as in•irate•.
Date Issued a. Registrar of Vital Statistics 2
a�� �f/�� (signature)
District Number 560 J Place 2, `�`" �'� J
t
iy
l I certify that the remains of the decedent identified above wer- disposed of in accordan with this permit on:
ilk. Date of Disposition z)italic Place of Disposition Inc t..-. owe.
Z (address)
Ui
{ ,
CC (section) A (lot number) (grave number)
Q. Name of Sexton or Person in Char a of Premises s li, 0,14,41
z I (please print)
iii 9
Si nature Title CUM*
(over)
.
DOH-1555 (02/2004)