Donnelly, Michael NEW YORK STATE DEPARTMENT OF HEALTH' '? CU,
Vital Records Section Burial - Transit Permit
Name Firs // �� Middle Last Sex
,/ G 4� r 0iWe/ �&
Date of D ath / Age If Veteran of U.S. Armed Fofces,
�zy" /)-- 7f,
War or Dates
li4 P e of Deat ,� f/, Hospital, Institution o //
Cit Town or Villag /Z /,CS Street Address �L //�" eu i� 7/
anner of Death Natural Cause 0 Accident 0 Homicide ❑Suicide W. ❑Undeter fined Pending
Circumstances, Investigation
ill Medical Certifier Name h /� / Title . -
�CP 7 / /`'ke� �'i�)'`
Address
Death Certificate Filed District Number Register b
0, Townor Village V s��//s _ (Z O/
■Burial Date / ery or,Cjematory/� •r-�
❑Entombment /�)`// /1-- //if/O/? C /ZI0G uZdi.7f/,vi
Address
Cremation �j, - 2srJ Ca ' � i" /,,2-/d, .
Date Place Removed
Z Removal and/or Held
❑and/or
Address�;;
CA
Hold
0 Date Point of
t 0 Transportation Shipment
C by Common Destination
Carrier
•
❑Disinterment Date . Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registrati n umber
Name of Funeral Home@(fir���j—.!ii� ��d `7 �./ 69,)/4/.
Address
fAx-2, s--7-- '..,4__ --,-7 2:-e-r-- c-,,--,-, .—c _. - 7.)_or-7 >
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
•
in
it Permission is here gra ted to dispose of the human remains described above
s in ' d.
Date Issued�� /��-Registrar of Vital Statistics Alai
(signature) f�District Number f Place (t. 7--- p r6-P .i.,-A-./4-/ �/ �th y.
s I certify that the remains of the decedent ide fled above were disposed of in accordance wi((t••hh this permit on:
LEI Date of Disposition 10_2c-1-1_ Place of Disposition "(r*tOt•+-) l rvrk..TOrti-v
1 (address)
Cl)
(section) 4 (lot number] - (grave number)
ct Name of Sexton or Per on in Charge o Premises ro - '
t#114
f (please print)
Lt! Signature Title Ctiit x'JN a IL
(over)
DOH-1555 (02/2004)