Zibro Sr, Mark NEW YORK STATE DEPARTMENT OF HEALT- •
ti 4 -id
Vital Records Section Burial - Transit Perm it
pli Name First Ole Last Sex
Qr(C A -ai or cI Sr o
�../ : ': Date of eat/� � Ag If Vet an of U,S, Armed Forces,
II r<7� l Z{� /
� 1 5 W —
0 or Dates
Place o Death / -� n Hospital, Institutio or
City, ow or Village4rilitA 1t Street Address ►S),,l P,- ge6c
p Manner of Death 'Natural Cause Accident E Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
in Medical Certifier Name �" Title
0. �T �._ MOS /)1
Address
Death Certificate Filed District Number Register Number
OW
City, or Village t� )+` 51 ca
< []Burial Dap CC Cemetery or Crematory
:<? ❑Entombment e c . S, b,1Lf (i.)ih V r eo e ire/1/Q3
/07
Adps
SCremation C k/- I C�` j u ease oc ivy /
Date Place Removed
Removal and/or Held
and/or Address
Hold
0
0, Date Point of
%a Transportation Shipment
by Common Destination
Carrier
zs 0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to j Registration Number
Name of Funeral Home itlt_kvi U Friney / 't 0 003 7
Address
9 - /) Si---. Jc\zre, S a1/47, iti'y r 2 i8-f
iiiiiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
i
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued f LA rig Registrar of Vital Statistics Oka P JW -'_\(31.___41., A,4'----
a
(signature)
> District Number c- ra Place j419 y!{r A / k'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition jLItif pi Place of Disposition L°i� Cr or;,--
(address)
III
W. (section) A (lot number (grave number)
i• Name of Sexton or Perso in Ch ge of Premises n volit
(pease print)
Signature ? Title f{tVa,
u
(over)
DOH-1555 (02/2004)