Jacquard, Josh if Why
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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Date of Death Age / � If Ve an of U.S. Armed Forces,
5 - 1 ) - 20(� 4(P War or Dates N/ O
• Place of Death Hospital, Institution or
City, ow . or Village � n c e,ILIStreet Address '4-2\/an Au Key Pc)
W Manner of Death❑Natural Case ❑Accident El Homicide El Suicide ❑Undetermined EPA Pending
Circumstances Investigation
la Medical Certifier Name •
Title
r MlchacI 6( k, rlca M6
50 3 r-D a d Address
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Death Certificate Filed District Number' Register Number
City, r Village St\,I Cr t. 5L0 58 1
❑Burial Date ! C etery or remato
;;::i ['Entombment 5- ( Z- r' ' i t'1 Q lie D re rrna l
Addre
Cremation u,ae€y S`J LA (l,J 1 kDate Pla
Removed
Z Removal and/or Held
i9❑and/or
� Address
Cl) Hold
O I Date Point of
❑Transportation Shipment
G by Common Destination
gi Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home i3jGk2 ri +'L tht
gil Address
ZK ( ltyi sr tow. c )m -IJE rvl Pstg.,
Name of Funeral Firm Making Disposition or to Whom
f. Remains are Shipped, If Other than Above
2 Address
AZ
LLB
Permission is hereby granted to dispose of the human re ains described bove as in icated.
Date Issued 5- 1 Z.-Z�(5 Registrar of Vital Statistic
.;
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(signature
is District Number C Place lo-n 0C St 0 nu � -<
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
lit Date of Disposition S j odic Place of Disposition f„,,;,,t„, (arc (dr:,,.,
12 t (address)
to
cc (section) / (lot number) (grave number)
taName of Sexton or Person in Charge of Premises /4" Sty
(please print)
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Signature Title t°"Ilk+"f'(Irt
(over)
DOH-1555 (02/2004)