Curry, Michael �14,
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last �x
1\A 1 C. EPIC e, I S c(,, -( J",% ' i
i,
Date of Death Age If Veteran of U.S.Armed Forces,
3-- -- I -- &i - War or Dates k(1
Place of Death Hospital, Instituf n or
City, Town or Village 1 1)(I(ki) L K_L.._ Street Address(I-10 in Lcu k/5 i cI
Manner of Death❑Natural Cause ['Accident ❑Homicide 51 Suicide �Undetermined Pending
Circumstances Investigation
Medical Certifier, Name Title
\ I M"q I )I Ck 'ie n n l nC S Co rlc-,----
,--7 .J Ad ress J
1 (D I-Cn) iaKC NY
Death Certificate Filed District Num�h r Register Number
City,fio�)or Village YyII 1 V\ Lu k k,
3
❑Burial Date 7 mete pr Crem ory
El Entombment 4 ( — 2EC tine �`iei,Z, C -t ilialC19_
Addr ,�
E Cremation 'l,((�1'15b,t Iti i R i1
Date / Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home jv 1 ) I 1 f,r H.( o f,4 61 1 4 yr C//qq
Address(-F3 1 .. -Cl - Rik (13 // )( !C /-1 th.kL , _i 4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3-3 l-/,s-- Registrar of Vital Statistics a
ignature)
District Number 12d S 3 Place 44,61....,t_ p-ke. / N y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II/Zfl.s Place of Disposition giv E,..1 Crw-'�c!,—
(address)
(section) f (lot numb) (grave number)
Name of Sexton or Person 'n Charge Premises (,4,..4.. `\J`"'4''
' ( ase print)
Signature
G ` Title rn WM
(over)
DOH-1555(02/2004)