Farry, Richard NEW YORK STATE DEPARTMENT OF HEALTH ' �T,C
Vital Records Section Burial - Transit Permit
Name First ,- Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
-3 11912 o 19 1-4 War or Dates
1- Place of Death Hospital, Institution or
Z City, Town or Village Street Address
IIIW Manner of Death❑Natural Cause Accident 0 Homicide 0 Suicide Undetermined El Pending
Circumstances Investigation
0
Medical Certifier Name Title
Awn rb ,r,- Mau \ ► im P10-
Address
Death Certificate Filed I s District Number s / Register��r
City, Town or Village 1�O^nS Fes, 1
DBurial Date Cemetery or Crematory
Entombment Address
Cremation 2 \ Qu U g-O J Q,ccan,O \ l v ' f 2-$Cy
Date Place Removed
g❑Removal and/or Held
and/or Address
I= Hold
(I)
O Date Point of
f Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home (Y\0) iC., I rw. , „,_Q )4 rr\.2 a t 0
Address
1310 n'1a ; n &- Yk c-A/Ms Fedk 1 2(02
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;; Address
te
tU
Permission is hereby ranted to dispose of the human remains des ibed abo e a i ated.
Date Issued ,07 /-520/`_ Registrar of Vital Statistics o
(signature)
District Number 5Z O/ Place ./e. A-15 Ay
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 0
tit• Date of Disposition '1-f1'('1 Place of Disposition ZtlAK., Crfr...-vrst•--
a (address)
tits
ta
CC (section) (lot number) c., (grave number)
ta Name of Sexton or Person in Charge o Premises a tr,t N Jevoiti-
2
(ple se print)
W t c
Signature Title Crii‘rtiftiet
(over)
DOH-1555 (02/2004)