Starzec, Matthew NEW YORK STATE DEPARTMENT OF HEALTH 3 617(
Vital Records Section Burial - Transit Permit
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Date of Death Age If Veteran of U.S. Armed Forces,
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Place of Death Hospital, Institutio or
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a Manner of Death rz Natural tause 0 Accident n Homicide n Suicide D Undetermined 0 Pending
tU Circumstances Investigation
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Death Certificate Filed District N Register Number
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Burial Date etery, r Cremat
❑Entombment 07 a3� 14 i rye v t e i�,h airor{
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JCremation lyj L.(e.0nsb
Date la ee Removed
Z El Removal and/or Held
and/or Address
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0 Date Point of
Q Transportation Shipment
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Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-bi )J .e r' ��b_flefejj 7)- 9/Ii`. /i c. Q 03./I
Address aGu U 1 S L��, ,-ki-n1 AA/ /g4`f'
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
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fl` Permission is hereby granted to dispose of the human r ains des r" ed above as i ica d.
Date Issued 6`1 =31 r 1 q Registrar of Vital Statistics
(signature)
District Number) s Place --- -
t- I certify that the remains of the decedent identified above were d posed of in accordancecf with this permit on:
:LL Date of Disposition 1-2�i`hI Place of Disposition ,H)u,_, C w/td(--
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re (section) (lot numb (grave number)
G Name of Sexton or Person in Charge of Premises ,.r 3tn'4
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U Signature 6 Title Ca"Itflr4C
(over)
DOH-1555 (02/2004)