Colleary, Michael NEW YORK STATE DEPARTMENT OF HEALTH tQY
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
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01;c 4A o f .- e o !le Q t-,
Date of Death Age If Veteran of U.S. Armed Forcds,
O Y- a 9. — ffir <Pd War or Dates _
I . Place of Death Hospital, Institution or
Z City, Town or Village S Street Address 6 4/ ee�p I-- Ai I'/� ,Q,..
Manner of Deaths Undetermined Pending
t Natural Cause �Accident �Homicide �Suicide � �
lit Circumstances Investigation
ill Medical Certifier V:-
Title
t4 1-se�h Sc�Al C_rn , (1 0
e 1 Address � afire;
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Death Certificate Filed District Number Register ber
City, Town or Village �c,A 1--�f- _ `g I
❑Burial Date Cerpetpry . Crematory, �--
❑Entombment f` , - a��0
Address
emation OLM---e-S-3 S 4 0 J'lJ
Date Pidce Removed
Z Removal and/or Held
2: ❑and/or ----
It Address
Hold
to
Date Point of
❑Transportation Shipment
Q by Common Destination
TA Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home w,i�k_ , K// foyer' / 110R,s-- a 0-,C(
Address
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nein, _ IA /0-7( • / g(F 7 0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
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3 Permission is hereby granted to dispose of the human re ' s described above as indicated.
Date Issued Registrar of Vital Statistics 4.4.-./Li,c4.A.__SLucitA_Afi _
(signature)
District Number 003 Place c� l
I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
Z
1 Date of Disposition th f►S Place of Disposition the Cr+ or .
(address)
111
ta
CC (section) (lot number (grave number)
Ct
tii Name of Sexton or Person in Charge of Premises [ „Vir '
z dr (please print)
1LI
: Signature ,�" Title wept
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(over)
DOH-1555 (02/2004)