WEcbeckn, Norman NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . . w Burial - Transit Permit
Name Firs. rr Middle Lastt SA14k
Norti.h.A I' tjec ki w�
Date of Death / Age If Veteran of U.S. Armed Forces,
7/c he'll -7 v War or Dates i `t 43—(f1,
i- P of Death Hospital, Institution or
City, own or Village _Tx, i- r 4k, Street Address
anner of Death�y Natural Cads‘ fccint Homicide Suicide U �etermined Pending
ILI `' Circumstances Investigation
at Medical Certifier Name Title
gt. >t e r A c A afrA mi)
Address
al( a,r 54r 1, )a�� /. ZC
D-. . Certificate Filed , Disltrict Numbe Register Number
: •wn or Village ��x r-t, `' 1
` :urial Date / Ceme ry or Crematory
: ❑Entombment 7/ r 2 o I "ne-✓,t.., ac'"..o'-to r
Address
Il MCremaiion 62.-,L e.cA$.4-) �r Y .
Date j? Place Removed
Z n Removal and/or Held
and/or
F Address
CO
Hold
0 Date Point of
oi Li Transportation Shipment
Ls by Common Destination
Nii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homed y,r,rt "I u.te-/i ( 44--n--c_ b e). `t
Address
lc r ow f e_ �i. . . /Q ). % _7,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
lit
9` Permission is hereby ranted to dispose of the human remai es ib ab - dicate
Date Issued / Registrar of Vital Statistics
(signature)
Mi District Number Lt. 5-0 j Place ..__c S
I certify that the remains of the decedent identified above wer dispo ed of in accordance with this permit on:
al y C &_
Date of Disposition '��-illy Place of Disposition int `�
(address)
ili
Mk
IC (section) (lot nu er) (grave number)
Name of Sexton or Pe on in Charge of Premises ,et - w40-
5 (please print)
Signature ,Ad Title ove Winil
(over)
DOH-1555 (02/2004)