Durkin, Devin NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
11 Name First Middle�d �d Last ►��crkin Sex H
Date of Death Age If Veteran of U.S. Armed Forces,
tel62 u 12a 15 3q War or Dates
e of Death f I S ospita G Jens Fa 1 I S
.�--6 len S 1=a s
anner of Deat Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
iti Medical Certifier Name Title ,,
7c lei \i o`.y
Ol ii Address IOC) art_ St,) 6 LUIS Fa 11 S, AN )l?Q i
h Certificate Filed G Lim S Fail District Number ��O( Register Number f��
�i eiii
ity, r�Fillage .
Date i Gemstefy€Crematory
❑Burial Si ZL9 120 I 0 ne, V:
�� Address Oi -CO Rd Qu..eellsbisi\/ AN iz�
`►. Cremation � ! J
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
C Date Point of
aQ Transportation Shipment
5 by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
< Permit Issued to Registration Number
ti Name of Funeral Home Pa ;i ,K ). Rota( F,jo r_ MNC' 0I J
Elf FT)
Address/ C 0 u ,u 6 U 1 1 c y /2.e-� y
l�'F Fi7 J b� �%
Name of Funeral Ft Making Disposition or to Whom
E. Remains are Shipped, If Other than Above
Address
it
AI
:' Permission is hereby granted to dispose of the human remains described above} as indicated.
y Date Issued 3! 2S//.°c Registrar of Vital Statistics �"'
/,, (signature)
District Number S' 60 / Place 6 s ' s , y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1„-
WDate of Disposition"&715 Place of Dispositionl?f1e V9 C r f
2 (address)
W
tRCC (section) jot niimbecy (grave number)
0 Name of Sexton or Pe - Charge of Premises
(please print) . . -
. Signature
Title r��� ff.� ��rt//��e ?
(over)
DOH-1555 (9/98)