Stark, Jared i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit emit
Name F t Middle Last Sex
Date of(�eat Age If Veteran of U.S. Armed Forces,
�a//aef/t/ 69 War or Dates /y63/36.
1-4 PI of Death Hospital, Institution or �� /�
W it own or Village 61445/z /7J7// Street Address / i�p i ST CA"ri / l4 'y
a anner of Death( ' atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
`T Circumstances Investigation
W Medical Certifier Name Title
e//// 6.7(5615 s-
Addressie°- & ,Ar /c /
D--th Certificate Filed District Nu er Register umber
Town or Village 6/ m s/—74/ d 7 VQ 9.
=unal Date 4,�/ Cemetery or Criatory
Entombment �� 7 Y �' '-2e4ve P/ ertv,24,A,e -1
Address
Cremation tl'f',Pn f //Zfrf l
Date � Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
t
0 Date Point of
tR 5 0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date .Cemetery Address
❑Reinterment Date Cemetery Address
PermitIssued to /�+y�'1/,J 12/ - t4e- �. /j/, Q Registratior)/// mbar
Nameameof Funeral Home / "n
Address 4 �.eai'1�,�' —d-/ . / 7/ 9z/ ,t,y' / )- -7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
Lu
` Permission is he eby granted to dispose of the human remains described abov asi icated.
!_ Date Issued S7.0J ' Registrar of Vital Statistics ,f `
(signature)
District Number 560/ Place /-' 1`i4 / «f/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IJ! Date of Disposition ciiihri Place of Disposition �,ui,L., C ry-.
(address)
11
to
is (section) of number) (grave number)
CI Name of Sexton or Person in Charge of Premises4,..4.0._.
�`jj�
QNNi�
r A:
, (p/ehse print)
Signature �� Title etas
(over)
DOH-1555 (02/2004)