Litwa, Edward NEW YORK STATE DEPARTMENT OF HEALTH L Zv
Vital Records Section _ **
Burial - ansit Permit
IN Name First `Middle Last Sex
fl Ec)w A rr)
>- Date of Death f Age ` 1 If Veteran of U.S. Armed Forces,
' Ao . 2 7 a015 i se- ; War or Dates /467— /`I'7,
Place -' Reath l J I Hospital, Institution or
2 City, Tow or Village / (e l Street Address a , R, _ • /?j ,
Mannerof Death u Natural C.use Q Accident Q Homicide 0 Suicide Undetermined Pending
ILI Circumstances Investigation
Medical Certifier Name Title
;n< Address
+f' 3/q $64 y GJ • Qaeg/Vs keiLii %1 f'/MO y
'<s Deat ificate Filed District N mber ( Register Number
1 City, Tow or Village / oney E
Date ( mete r Cre atory
E Burial ! u as # i N Vle O1 i2e/nAz V
Addre ��yy-
Cremation 62tmei L i ,-- 't. -ws'1u iv /•v/,hp-
Date Place Removed
0 ❑Removal _ l and/or Heid__^
and/or Address
Hold I --- - ----
Q Date I f:;int of
Nn Transportation j Shipment
a by Common ! Destination
Carrier
Disinterment
Date i Cemetery Address
0Reinterment Date Cemetery Address
<: Permit Issued to I Registration Number
iiV ex
Name of Funeral Home aV\ u'(l era 1 }�bM O`'3 0
Address , N`11 Lo - Skrt e�- Q v.eersbLk.r�f " 12- 0-1
Name of Funeral Firm Making Disposition or to Whom
44
Remains are Shipped, If Other than Above
Address
Iiiii Permission is hereby granted to dispose of the human re,atys described above a ndicated.
>l` Date Issued b- 7 e ,' Registrar of Vital Statistics,/ Cl`.:,� /e ��� 1'
(signature)
`' 3 District Number VS- g; Place
f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zuj Date of Disposition $f li)I S Place of Disposition 4 rw Um) a<y„r
2 (address)
' (section) (Sot number (grave number)
Name of Sexton or Person in Charge of Premises '•1m � 3t»�►iofi
Z (please print) f
W Signature4 Title f(ZP11 1_
(over)
DOH-1555 (9/98)