Mandel, Cynthia 03/21/2009 09.29 518 624 2010 r TOWN OF LONG LAKE /7870 P 001/001
Sr (II
NEW YORK STATE DEPARTMENT OF HEALTH(
Vital Records Section Burial - Transit Permit
Name First Middle Las��tayst Sex
�V1`�'j1101 n
I
.; ,Date of De th Age If Veteran of U.S. Armed Forces,
1- ( 1 20(� 5 War or Dates I V o
Place of Death LouHospital, Instituti 1 /
City, ow or Village Street Address "66, I\Je xo,'11.� kd
2 Manner of Death Undetermined Pending L. Natural use Accident Homicide Suicide �
Circumstances Investigation
w' Medical Certifier Namg Title
3 d Slat faz dres 2 'n ke-t± /V L5100
Death Certificate Filed District Number Re lister Number r
4;_City,4 or Village -Lo iyi LCc...e n6ef, I
4 QBurial Date J_ � yC etery or' Cremato
El Entombment ' s 1 5 J 1 l+ / 1 n e, •V i e 11� a
-rz-v
Address
E21Cremation G�-U--1&')bU
Date Plac�moved
Removal and/or Held
and/or Address
Hokf
Date Point of
Transportation Shipment J
a by Common Destination
Carrier
<'• n Date Cemetery Address
> 'Li Disinterment.
';!„[]Reinterment Date Cemetery Address
Permit Issued to n Registration Number
' Name of Funeral Home I v1( // r 7� I11 -rt 1 /AL. Q//9'9
'`i Address 35 7 - e 3, 1 n la it) La .._ lc)6'ya
„:„.
<; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address •,
g . .
>f Permission is hereby granted to dispose of the human re ains described above as . boated.
Date Issued I- I y -1 `T Registrar of Vital Statistics 4/4.1.)`��`-_(signature)
;;;,; District Number aosi Place rU1)n Djkoni, 1 yx.k_e_I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition j/t.If( Place of Disposition KS„,eV�w 60-ti f+uv
(address)
N
(section) Jj of number (grave number)
0 Name of Sexton or Person Charge of Pr ises i,S r t►iNll-
g / (please print)
ILL.• Si nature ` _ Title t,1L�►�12
>„ 9
Arlo--
(over)
DOH-1555 (02/2004)