Oddy, Kevin NtVV YUHK STATE DEPARTMENT OF HEALTH e
is,
Vital Records Section Burial - Transit Permit
ni Name Firsts / Middle La �y,�,Se ,
✓ Mii Date of Death Age If Veteran of U.S. Armed Forces,
Cal— a - Z0iii 5cf-- War or Dates (3yi - 16PS
14 a of Death Hospital, Institution or
' ;� own or Village ,4 / Street Address A� j/)U'f 4
-nner of Death atural Cause El Accident 0 Homicide 0 Suicide riUndetermined 17 Pending
Mt
Circumstances Investigation
tu Medical Certifier Name Title
o
�ARLY5. j) j1 Sco-R.,�-,•o 1
Awic u - �3 N� iike,Address 4,,,,,,,,
-- Certificate Filed District Number Register Number
own or Village P� N''
Burial Date,,_, Celt ry Crpr�►at elz-E0,A4rolz-V
U1- Its -�iq 1
4 ��//I
ntombment Address ,�y,/
emation t ICZ4evr-A`zP a L %�vizi io
Date ) Place Removed l
g in Removal and/or Held
and/orHold Address
fa w"
I Date Point of
Transportation Shipment
C! by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to t�� { �, / Registration Number
Name of Funeral Home V"► I`I tt4l/t t~ 1 t 010
>'; Adq e,�s �QVAtIvali v 6,A AU 1-
MI Name of Funeral Firm Mating Disposition or to Whim
• Remains are Shipped, If Other than Above
• Address
tt
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' Permission is hereby granted to dispose of the human remains described above as indicated.
<`i Date Issued OH I L{ Registrar of Vital Statistics(-----.. —`
(signature)
District Number Place A1.47,1* rP.y.
mi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tU Date of Disposition Place of Disposition
2 (address)
la
til
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
2 (please print)
II Signature Title
im
(over)
DOH-1555 (02/2004)