Kosinski, Christopher Nt # 7 yq
NEW YORK STATE DEPARTMENT OF HEALTH ` p
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
C Pz5TbP1Vd P Ko5Dv5 Ks Mro1+-E.
Date of Death Age 1 If Veteran of U.S. Armed Forces,
0 3 30-2015 110 � War or Dates N/A
Place of Death I Hospital, Institution or
City. T=ew�. r-Vtti#ege 7/2-I ; Street Address r30o MR5SAcr-Iv5E7T5 fIVVN LE.
a Manner of Death L. Natural Cause O Accident Homicide Suicide O Undetermined ri Pending
tLt Circumstances Investigation
isj Medical Certifier Name Title
0 MzcttgeL Sy4..iQTeis M�
Addres
ib 9-4AD STR€61- I vo 'r (`a-R#) i m ijl%$
Death Certificate Filed 1 District Number I I Re gister Number
Y City,T�lage I l ai
OBurial Date Cemetery or Crematory
v Y -0 2- 1015 Px-vev.c-1.0 CP.6merr
O Entombment
Address
` EICremation ati&C,N513uQy 1pJ yoAk- .
Date Place Removed
Removal and/or Held
and/or Address
Hold _
0 Date Point of
6 0 Transportation Shipment
a by Common Destination
Carrier
O Disinterment Date f Cemetery Address
0 Reinterment Date Cemetery Address
1 ,
Permit Issued to 1 Registration Number
Name of Funeral Home 41)1OFf% FVnJe tine 1 ONZ5-
Address
134. WA1212EN Sne-ee 6(E415 Fm--S, NY t28oi
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
>E
tL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued &-\-IC Registrar of Vital Statistics i1 t e,
(signature)
District Number '101- Place
I certify that the remains of the decedent identifie above were disposed of cordance with this permit on:
w Date of Disposition N/Z//0;" Place of Disposition Zia., '"1'�r••,--
(address)
ill
tin
Ir (section) /� (lot number; (grave number)
gName of Sexton or Person in Charge of Premises - 6Ii Jaar`/4}'
ZA ( lease print)
4 Signature4 Title C71 W—
(over)
DOH-1555 (02/2004)