Spizuco, Paul NEW YORK STATE DEPARTMENT OF HEALTH E
Vital Records Section Burial - Transit Permit
Name First Mic le Last Se
__?4,4,
Date of Death Age If Veteran of U.S Armed Forces,
a7a`,7A0/ -t k War or Dates V J'jY—$;
I-- P . e of Death Hospital, Institution or
own or Village, ' ,; _ Street Address Dela �.
3 T anner of Death Q Natural C se Ac . ent 0 Homicide ❑Suicide Undetermiricd Pending
W Circumstance Investigation
LAN Medical Certifier Nam Title
r.cl
Address � e� � U, r !��,
,3 ,+`( r _
De.. I Certificate Filed / District NurWer Register Number
,`P nor Village f' r,�,-�.y�_— r
f-5'v
■Burial I Date Cemetery rematory
❑Entombment . _ )- /")l �+'"/7 , ite v� �
Address
[Cremation �Sbv r Alei Yr�
Date J 'Place Removed
1-1❑Removal and/or Held
and/or Address
t Hold
CO
0 Date Point of
Drip Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to — Registration Number
Name of Funeral Home C4)n^?r- Acr _ �4./e „J.- oat/ 71�
Address C
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
III
®' Permission is hereby granted to dispose of the human re ns tisry7dappov.e7is indic ed.
Date Issued V.a)- J/' Registrar of Vital Statistics
/ (signature)
District Number tic S-v i Place Y
I certify that the remains of the decedent identified above were di used o i ac rdance with this permit on:
ILI1 a?
• Date of Disposition ���S�)'1 Place of Disposition l� � � --
2 (address)
w
Ca
CC (section) (lot number (grave number)
Sartitt-
• Name of Sexton or Person in Charge o Premises he`
«fir lease print)
tii
Signature Title CaCMAVJk
(over)
DOH-1555 (02/2004)