Bogrosian, Thomas NEW YORK STATE DEPARTMENT OF 1-:FALIH9- '�
Vital Records Section Burial - Transit Permit
Name First,___ Middle Last 1 Sex
1 lkp''`fl '14' S 'W:::?( I-cG S l A i ) t�
Date itD / I Age If Veteran of U.S. Armed Forces,
� 3 (� I War or Dates
I-- Place of Death t Hospital, Institution or
Z City, Town or Village Cj�e 1...)s CALL-5 Street Address (, I.)7.5 V-G(��-S R cis e)' L
in Manner of Death raNatural Cause O Accident O Homicide El Suicide O Undetermined O Pending
titCircumstances Investigation
W Medical Certifier Name Title
0 ��A t L L S C.. tt)t-c.. 5 _� i= 1Z 1N/1 (T
Address
Rol CA Q.C LA V_7 C;)vtt &) -c2,L)a---► s.J`1 (2-B o Li)�
Death Certificate Filed ff i District Number Register er
City, Town or Village lLLC iJS VA`L, I, ,5-6,O -j
OBurial Date Cemetery or Crematory
❑Entombment 31 a O o i P 1 w� t C 1., ) 2-(:--M -A--cc:, �'l
Address
.ICremation 0C_,Av<c-, z. VT, ,) Qvt'L tt- S Q" 2`1 N`'\ ( Z5tf
Date I Place Removed
Za Removal i j and/or Held
and/or Address •
P Hold
U?
Q - Date Point of
Oi O Transportation Shipment
5 by Common Destination
Carrier
Date Cemetery Address
O Disinterment
O
Reinterment Date Cemetery Address
Permit Issued to 1 Renistration Number
Name of Funeral Home M Gy nar d Aker- F nc r ej ;yw.__ i o k V
Address
11 �a- y e fie S. , Q u,c umbu,r y , ti e v,..3 yur k 12 sic”--1
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
,2 Address
re
W .
11. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued G 3/,P7 ac15 Registrar of Vital Statistics ) 2-C�
(signature)
District Number`j / Place 4 j , c//. ,{VV/a?St/
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
Z
lif Date of Disposition c S Tjr Place of Disposition Prk/c Vir..1../ ,I,A,I, 7/t`
2 address)
ail
in
re (section) (lot number) (grave number)
ad
0 Name of Sexton, Perso harge of Premisesd �iAi'
Z / r (pleaje print)
UI Signatur ' — Title U fd2�' C_ •161-,
• (over)
•
DOH-1555 (02/2004)