Kingsley, Steven NEW YORK STATE DEPARTMENT OF HEALTH. .. it. 4 133
Vital Records Section Burial - Transit Permit
Anrik
Name Fir t Middle Last ' Sex i
Date ot Death Age` If Veteran of U.S. Armed Forces, i.
Off- a5a0i� Ss War or Dates
Place of Death . Hospital, Institution or __ ^
City. Town or Village`I Q.SLE.t-NK dve_C, Street Address 1 Qw ��izs k..� lot
Manner of Death a Natural Cause D Accident [- Homicide n Suicide n Undetermined Pending
_ Circumstances _ _Investigation I
Medical Certifier Name — Title
Address
S1. 1-kPvi(,t&Np Au tr Guta p..)s V-A`. ...s , tJ`v ta5O\
Death Certificate Filed ' District Number . Regis er Number
City, Town or Village AV-IL-CPS %LLV 57-0&O
' Date Cemetery or Crematory
Burial a 1'lb 120►S P 1 N C. V` 1�,\,3 Cs�..r oi,K4o�`7
Address
Cremation. 0-v k.K*.. k. �- (ate kw—CAL Ct] Qv% C�S(,-3 t�-t ,1J'k X . I C (
Date Place Removed
Z El Removal and/or Held
Q
I--; —
F,; I Address _--
— Hold
OH ! Date -
art •:�f
fai 1—Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
;Disinterment
n Rernterment
Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home.� �' no rof 1J .icZ 1 fLu)(77 CZ% //pJ-»c r-
Address --
I La r 7c C)f. , &LLCiris 'j , .f4few `I') 1�1r?C&`I
Name of Funeral Firm Making Disposition or to Whom y
Remains are Shipped, If Other than Above
t'¢` Address
Permission is hereby ranted to dispose of the human re ins deicribed above as indicated.
Date Issued`-)/�� /`� Registrar of Vita! Statist' G,ib `�J
(signature)
District Number ,562(00 Place�liltorzyj,,ski,__ / (Z .•
I certify that the remains of the decedent identified above -•-re disposed of in accordance with this permit on:
EDate of Disposition 3I 4 _ Place of Disposition ELL
2 (address)
ttJ
!� —-
CC (section) of number) (grave number)
Name of Sexton or Person in Charge of Premises _—_�
(Z (please print)
IW Signature Title l il1p'V.
over)
DOH-1555 (9/98)