Duell, Craig NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
: Name First-,
,,.... Date of Death i
/0 12,‘2 //71-- ..S—D
Place • a,- hth / Middle
Age M s•IT I-I E\J -Mgt,4_
1 If Veteran of U.S. Armed Forces, /
i War or Dates
.pital. Institution or J\J ,SiTinitC
--- -
p_ciq own • Village QOar/J.S.A U c\:-..S.treet Addre qos Ctu:vo 6t.) n)1266K 42
Man r • Deathlkatural Cause fl A -ident U Homicide Ei Suicide n Undetermined 11 Pending
rl "-a Circumstances ' 'Investigation
rr
Medical Certifier Name Title to
4) /NI z ca„) )).,.)46,zw\r‘
•th:. Address r --7-
E$ Fo
r____CTYL ix A I
:RI Death * " ate Filed -)
District Number I Retster umber
tg Cf , o Village L. OW,..51 64-0 LI ; 7
... r.-1 Date Cemetery 1 Cremtho
.:.: LJ Burial tt) I 77
Cremation
---1
Address .--_-)
0-0)461 11-43- tibi4,-"D 4
Date Place Removed
:ri Removal
,•!.!""'-'and/or Address
Hold
Al Li r—i Date 1-Thoint of
Transportation Shipment
0, by Common Destination
-
.. Carrier ,
Date Cemetery Address
Disinterment
I
_ -- -
Date I Cemetery Address
[J Reinterment ---1
Permit Issued to Registration Number
P Name of Funeral Home Hetynar CI b. Zaftec Ft-wer cli florae 01130
t%it A dd ress // LaraklatC 31-• , alAkt."&Lad , 'Out) Liorit [Q,R)1
mi Name of Funeral Firm Making Disposition or to Whom
.,,,.
Remains are Shipped, If Other than Above
t.:.; Address
MC
M. Permission is hereby granted to dispose of the human reai , esori
44 in icated.
Date Issued \ --- 1_-:_I`-( Registrar of Vital Statistics
ature)
‘.4.1 District
A Di Number A5(iS1 Place
.:..
. _ I certify that the remains of the decedent identified abo here disposed of in ..4, . - with this permit on:
00,1
6 Date of Disposition io iiiily Place of Disposition AD,,....., Ci-• P.'
2 (address)
titil
to
ir (section) (loVitimbert.4. (grave number)
° Name of Sexton or Person in Charge of Premises
ti /t Z (please print)
ill Signature /-1- „el_ Title CaerttiWk
(over)
DOH-1555 (9/98)