Lamica, Earl it 0
NEW YORK STATE DEPARTMENT OF HEALTH , ��f°
Vital Records Section /' Burial Transit Permit
Name First Middle Last Sex ,
Eat ( El -( LG,m 4 c !'Lt41 to
Date of Death Age If Veteran of U.S. Armed Forces,
,'—2 4J / I/ $2 War or Dates /1icrs /�7 5'2_
) Place of Death Hospital, Institution or _ '�• � �
City, Town or Village '�aSp� , Street Address `J le ?', 1 /Users; `
ui
a Manner of Death jNatural Cause 0 Accident �Homicide 0 Suicide Undet fined Pending
Iti Circumstances Investigation
ca
tu Medical Certifier Name r-- Title
44 iee4 z
Address I l..1,i.,A,re..-ce .S t ,54e'u4-8 5, 1L'$ 1286C
Death Certificate Filed ! �10 District Number ( Regi err Number
City, Town or Village Ci.
❑Burial Date Cem ery or Cre atory
9_ 2
...... / Li
❑Entombment Add n
Cremation a
i,cC,� „/' a'� 4),.�t, ) u.I /U
Date • Place Removed
Removal and/or Held
and/or
H Address
Sl
Hold
0 Date Point of
tipTransportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date . Cemetery Address
Permit Issued to /� r Registration Number
Name of Funeral Home (0Yrt J;0 N tea.{ f e,t,vvt R,., CSC,,^,Trrc 003 t q
Address l U .Z m A� k j� Sp. � 12—F
llp Name of Funeral Firm Making Disposition or to Whom
1-. Remains are Shipped, If Other than Above
Z Address
I
LU
A` Permission is hereby granted to dispose of the human remai esc b ab°� - dicated.
Date Issued I—( _ ) ki Registrar of Vital Statistics i -
(signature)�
District Number L fsv I Place ft.1-4,4 f_
S . /V
I ceI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 9121 ly Place of Disposition 4/.. cm.Au i_
2 (address)
in
Cr (section) d .(lot number) (grave number)
ci Name of Sexton or Person in Ch ge of Premises ',it In,*
kr lease print) M
ii Signature Title C�
(over)
DOH-1555 (02/2004)