Loading...
Martzinek, Jean NEW YORK STATE DEPARTMENT OF HEALTH ; " Vital Records Section Burial - Transit Permit Name First 37Can Middle Last H 0 ai t Z;CY L Sex Date of Death 1 ''zo ,14 Age 83 If Veteran of U.S. Armed Forces, War or Dates 2 Place of Death �� E�WO = •., ns i ution e+ v-h lc&s©n Town O Manner of Death 1 Natural Cause 0 Accident 0 Homicide n Suicide ri Undetermined 0 Pending W Circumstances Investigation ul• Medical Certifier Name \ a t Title M 0Addees Death Certificate Filed J District Number Registber To F4. Edwc( )7S @ ' d� ❑Burial Date `,\-2-0\VA eel u i ry o remator p (),._ ❑Entombment -- — CAQAddress suit remation Wa / �04s)..nb LLA.,_ ► � v2-20 `4 Date Place Removed iZ❑Removal and/or Held — and/or Address t Hold Q i - - Date Point of ai 0 Transportation Shipment G by Common Destination Carrier Disinterment Date I Cemetery Address Reinterment Date Cemetery Address Permit Issued to I Registration Number Name of Funeral Home t' o,,/f1Cu j 1 , €x .er Vi nC r c i Lry 44-- _0 # ! 30 Address k OAC y Q H ) . , C e-'•C-n� Iry , fv e \Ns 'Jur V. 12 sd 6 t--\ Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address CC w — II" Permission is hereby granted to dispose of the human re 'ns described ab ve a indicated. Date issued Registrar of Vital Statistics ry (signature) District Number 515 5 Place I OW-it 0-6 &ckuo.id R.& I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Place of Disposition /171 ,, (.: - arm Ul Date of Disposition li/ZIlIy bt (address) 1W Cl) (section) d.,:.,(kii, (lot number (grave number) QName of Sexton or Person in Chargeof Premises o°vw iZ 4 ( ease print) W Signature __ Title C01.1 4- (over) DOH-1555 (02/2004)