Corentto, June NEW YORK STATE DEPARTMENT OF HEALTH • 1 1 # T P
Vital Records Section Burial - Transit Permit
Name First I Middle Last Sex
is M Ara OAtJ ( aCzc.: NYTa
Date of Death /I Age Q If Veteran of U.S. Armed Forces,
/)S D g War or Dates —
-. Place of Death Hospital, Institution or
ZCity, Town or Village G Le tv Street Address ( L-E Ns 4''A( (-.. l-(c,S' a Ai--
W Manner of Death Natural Cause ❑Accident 0 Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title M
CI TALL �A c_�ry v
Address
`3-4L3 MAt/0 5-1 Ula_v_ct0sguQ_G N`A fa-si‘ S
Death Certificate Filed I District Number Register Number.
City, Town or Village G LG r'S VAS 5 D k 1 '
❑Burial Date Cemetery or Crematory
❑Entombment Address
❑Cremation
Date Place Removed
2Z Removal and/or Held
2/-1
and/or Address
t Hold
0 Date Point of
o❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
ElReinterment 1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home . M, CSaker Fuller cri-1 o;Y-f4_ 0 I 13« _____ _
Address
,1 Lakkyt. +1e S - , ( ueenSlOLkry , I\Se ‘,...s `Ayr L 12siOt-\
Name of Funeral Firm Making Disposition or to Whom
1-, Remains are Shipped, If Other than Above
a Address
IX
1:1 Permission is hereby
granted to dispose of the hum remains escribed above as ind" :ted.
:::: 6L1
RegistrarotatascsC/UP (1?sig/ Place e;r___ _.6 *71
_.,),,e
I certify that the remains of the decedent identified above w e disposed of in accordance th this permit on:
z
tI Date of Disposition b Icltc Place of Disposition gt,L., Ct
,,i._., .
a (address)
1i1
I (section) /� ((lot number) (grave number)
CI Name of Sexton or Person in Charge of Premises F. ,Se"-
[[p print)
#U Signature S 4lease
'"' Title `'
(over)
DOH-1555 (02/2004)