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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name„ First Middle , Last S
C1 - +��-z
I , ,),)11` 3\ Feillaki
Date of Death A e If Veteran of U.S. Armed Forces,
`f' ..1.3_AO 11 (p War or Dates N-
t- Place o eath Hospital, Institutio or
ii City(Tow or Village(j\ LI etil5 i.t,n Street Address oit 4 # 1Cl liNV
8 Manner of Death V� Natural Cause ��ccident ❑Homicide ❑Suicide ta ❑Undetermined ❑Pendin
Circumstances Investigation
W Medical Certifier Na a Title
ess
,itc 1(AA-)
Death Certificate File D. rict Number R inter Number
City(Toy or Village 9
❑Burial Date eter r Crema ry
;< ❑Entombment I /4 1 ZD)1- ne. t e.�.t) ( mica`._
Address n �
Cremation U-Q.-Q.�fLS U�ir? J
Date ) v Plate Removed
9 ❑Removal and/or Held
and/or Address F
W.
Hold
0 Date Point of
filS ❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
•
Permit Issued to A � Registration Number
Name of Funeral Home 1v` t ' I--Q,r ;�Q,}�(djj . l�(
.,...
Address t9 o� ��Tu---� t at, mac✓ I na I.CUA LCiak-``/ N y/ ) .4-2,
Disposition of Funeral Firm MakingDis osition or to Whom
Remains are Shipped, If Other than Above
;; Address
tr
UEt
Permission is hereby granted to dispose of the human r mains described above as indicated.
`s Date Issued / 1 `i 601\i,Registrar of Vital Statistics C ___Ot (38 n 4-----,
(signature)
District Number" Place_ orc Ous).. u/
I certify that the remains of the decedent identified above were disposed of in cords ice with this permit on:
ILI Date of Disposition NAdo( Place of Disposition , q‘,1 C ort,.�
(address)
C (section) d
, (lot number) (grave number)
QName of Sexton or Person i Charge of Premises P � ,/4N
2
( ease pant)
gi
Signature Title CiV Ntli d
(over)
DOH-1555 (02/2004)