King, Stephan # iii, -
NEW YORK STATE DEPARTMENT OF HEALTH "
Vital Records Section Burial - Transit Permit
04 Name' First ZdieLast / ,e ,
S%.��fi Al N 6 �'7i 44
Date of Death ' Age If Veteran of U.S.Armed Forces,
2//2c�/y 6
War or Dates
F- Place of Death / Hospital, institution or .r
W City,Town or Village 6 _ .5 C CI Street Address igp� iC}� i tcs ` S/�i7�-L.
p Manner of Death lenNatural Cause El Accident ❑Homicide 0 Suicide El Undetermined ❑Pending
v. Circumstances Investigation
0 Medical Certifier Name Attu. 8/ H ' Title q /
_ Address �'`�
.S7a' 7 MtA)s T A)YMPfrabtue6 ,*/I , `- -'
a, Death Certificate Filed / District Number Registrar Number
�
:' City,Town or Village riv, }y}C[S '/ 3 0
OBuriai Date f�, /�1l S/ � tASEd/Z_Crematoryery or t/7s .4
0 Entombment• Address / �/ /�
(.Cremation rP/ ,6&. �CD►� . atriws 641.4_ , A/7, A,?c
Date Place Removed
Z❑Removal and/or Held
- and/or Address
0 Hold
CO
O Date Point of
0IL Transportation Shipment
Q by Common Destination
40 Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home c j y - ��1.4 ►� 0/9.2,-C "
Address /2 b /QieA- Eivr 6> /ks f",,-(CS /✓ A:MI
Name of Funeral Firm Making Disposition or to Whom
Ii= Remains are Shipped, If Other than Above
2 Address
CC
W
0, Permission is hereby granted to dispose of the human remains described above as-indicated.
f.-:A Date Issued 7/ 2 / /4/ Registrar of Vital Statistics W0A----L1-,,'aq.
(signature)
District Number 5 60 I Place 6 c j \S / iv U
tiI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
UiDate of Disposition ").J-N Place of Disposition t V ‘7:.,frel-0 f,,._
ill (addres
CC (section) dr,b'Eci,ta—
(lot number) (grave number)
pName of Sexton or Perso in Charge of Premises 4^ll4
Z ( �
ease print)
W Signature ?t, 4Title et2E.0572
(over)
DOH-1555 (02/2004)