Lail, Nancy NEW YORK STATE DEPARTMENT OF HEALTH • # 703
Vital Records Section Burial - Transit Permit
1 Name f irst Middle Last i Sex
#.cy I. LAi F
ile Date of Death Age If Veteran of U.S. Armed Forces,
iiiiit /2 - 2V• Zd/V 4 / War or Dates
Place of Death ��// Hospital, Institution or
City, m or Village Lies rc,p Street Address lie /4rA reKA ,O,e.
:. Manner of Death 2-Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ❑Pending
Circumstances Investigation
:;.'":.! Medical Certifier Name Title
�oc✓Aeo M. L�Ec�tQs M,o.
Address /�1� / / `
3 L ARC LANE Jil i7L 3OO, ,.,JARA7436A, Ny,
:i Death Certificate Filed , District Number Register Number
•'•l' City, TOn or Village L y4s-rc2 o(o5 Z 10
Date Cemete or Crematory
❑Burial /iN L Viet,/ Cdecnu Td 4 y/ .
Address
Ilf Cremation
Date Place Removed
0❑Removal and/or Held
and/or Address
gHold
' Date Point of
ItQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
lin Permit Issued to � Registrat ry Number
Name of Funeral Home LARLE Toni f✓A)e,1Ac /mc� I4, , (�
Address w� ./`
, c . 8o) to 7, 4 6 /%A,N ST. 4d440Ai /TT ue..4. //j, /Z639
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
iiiig Permission is hereby granted to dispose of the human ema $d sc ib bove s indicated.
Eirl Date Issued /.2pc,/1 i Registrar of Vital Statistics iZt LiV(=
--. • (signature)
i �1'
District Number,(p ?; Place j2.tm er
4, ct, f_
I certify that the remains of the decedent identified above e disposed of inaccordancec with this permit on:
iljF ./ V Cc+'."C10 '
Date of.Disposition (-r:.(�1iM Place of Disposition ��. .�
(address)
LU
.
(section) number) (grave number)
..Name of Sexton or Person in Char a of Premises At
1 -%
/i, (please print)
L.. Signature (�- Title C'i '1rd` •
-
(over)
DOH-1555 (9/98)