Heroux, Leo NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section
Burial - Transit Permit
xiiiii Name First Middle Last/ Sex
Leo l a t-o P..c /T e. k "iuti
<€ Date of Death . Age If Veteran of U.S.Armed Forces,
s'7z f' �l 9 y War or Dates , g Li ti-l 9 tj
Plac ath H lotion or
a Ci Town Village a o r,JS B Street Addr (, Z- c c;U/6,LJ '1 IL
cy Manner of beatFh-Natural Cause Ac rdent Homicide Suicide Undetermined Pending
.41 � Circumstances Investigation
igi Medical Certifier Name r Title ;�
rLb„..,3 co,„., L-2v� ti J
Address ;17 ""j
id\Jb- . ae-r-hS 67-4-1 AI
<< Death ate Filed Dis t Nu ber R ter umber
»' Ci Town _ illage c. v - v
R OBurial Date _ Cemetery o�ematory�
4�
�� P� y,&_,
❑Entombment Address
<laCremation C t;yL, ) Qw ?1
`" Date Place Removed
Removal and/or Held
and/or Address
f' Hold
ati Date Point of
Q Transportation Shipment
15 by Common Destination
Carrier
El Disinterment
Date Cemetery Address
El Reinterment Date Cemetery Address
al Permit Issued to Registration Number
Name of Funeral Hor Funer o..i Lyy_ 0 I I ,Q _ -
m Address
11 La yQ t S4-. , QuLeensbu fy , Neu..: York.._ t2 o
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iiiiiii
"` Permission is hereby granted to dispose of the human remains describedri� above as indicated.
NI Date Issued joc Registrar of Vital Statistics+<f---\_____ � ( a_.°-Yi j
____----_____ (signature)
gni District Numbe c r Place )
I certify that the remains of the decedent identified above were disposed of in accor ce with this permit on:
Date of Disposition SI l%I!ts' Place of Disposition gi)....1 ... i..r
(address)
Cr (section) / (lot num ) (grave number)
cv
Name of Sexton or Person in Charge of Premises G ct,
z ( ease print)
Signature Title M
(over)
DOH-1555 (02/2004)