Simon, Edward NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Na First Middle a Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
I 0-ND-WI 3'1 War or Dates (, )LL
f Place of Death Hospital, Institution or
City, Town or Village (,(� b 1.1 Street Address"Li L(�e °avant is NA C
0 Manner of Death f)Jl Natural Cause n Accident n Homicide 0 Suicide Undetermined Pending
to Circumstances Circumstances Investigation
W Medical Certifi r Name Title
0 �05)yn �0c01df MI
Alddress
CILLerombitpd (\y'
. ,::, Death ertificate File District Number Register Number
City Tow or Village ateil,Q btA. 61 I d 7
.-.''''i❑Burial Date e1r�met or Cre y�tory
DEntombment l 7f 1 UI�Po�'^�
Addre Y
a Cremation LQtVkj
Date Place Removed
F.,.❑Removal and/or Held
and/or Address
H Hold
0 Date Point of
❑Transportationin Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to gistration Number
Name of Funeral Home ,r�.ritiz i I� (Q jJ
AddressC9'1- a a ird) 9.. lAkl- LIA7-eiriVi /2S4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
111
Permission is hereby granted to dispose of the human m 'n -esc - abo e indicated.
Date Issued Gp — 7_e9:0!4 Registrar of Vital Statistics '��'�`
(s- e)
District Number S(DS✓I Place l
fI certify that the remains of the decedent identified above were dispose f in accordance with i permit on:
Z /�
Ui Date of Disposition (0 thj Place of Disposition iMtj J Cri-4e! ..._
(address)
iii
ti
CC (section) Jot number) c (grave number)
Name of Sexton or Person in Charge of Premises C"r.3� So
(plea a print)
l Signature At_ Title filA1 ✓.
(over)
DOH-1555 (02/2004)