Russell, Michael . g 4-8 Sl I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle-7-1 Last Sex
M t thoe l (A) I LLelse,l I Male
Date of Death Ag If Veteran of U.S. Armed Forces,
1a _a3 a®1 - 8 War or Dates )lp
Place of Death Hospital, Institute n or J ,_
5, Ci Town or Village G l(s rQ I Is Street Address , � CIS 105p 1.111,I
O Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermineli D Pending
S Circumstances Investigation
ig Medical Certifie- A Name Title
41 v,
Marn 1 vicdowIfL. M1�
Address
Gl ' raIts 'y .
Death Certificate Filed ,^ District Number Register Number vn `�
'.: Cit Town or Village ��e.Yl S rQ(L.. L .(on t
❑Burial Date ++�� emeteryr or Crematory
(�
[(Entombment 1. 01q-aO 1i 1 i12` i CO `,to ry
_ _ _ oti
Address If
Cremation QYl Sb
Date J Place Removed
Z ❑Removal and/or Held
2 and/or Address
F" Hold
in
O Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier .
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Re_gtristration Number
Name of Funeral Home j_J( \Q ,t I I n c
Address of 1" Chtxr S� Loth_
o !l _ LUZLOL.L. nyl 24"%p
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
• Address
ir
W
P"` Permission is hereby granted to dispose of the human remains de cribee a ve i dicated.
Date Issued /2-4-(. ZO/y Registrar of Vital Statistics � /
/ (signature)
District Number J ,O/ Place 6.
Irk
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LU Date of Disposition 1 Z/ij/y Place of Disposition ,nt 6 t/....
2 (address)
W
Cl)
CC (section) (lpt number) (grave number)
O Name of Sexton or Person in Charge of Premises Asir
�a 'z.
(pe print)
ll Signature 4'- Title na el
(over)
DOH-1555 (02/2004)