DeZalia, Donald NEW YORK STATE DEPARTMENT OF HELTfk.,Ait
Vital Records Section Burial - Transit Permit
>; Name , O IU 6 I Mime s A bf Sex
Ni Dategof Death Age If Veteran of U.S. Armed Forces,
(/8• " �- / R2
War or Dates 0
14, Place of Death Hospital, Institution or /� �
City, Town or Village - 4 'fl{-VI Street Address SAY ST t1 '! '
O Manner of Death. atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Ui Circumstances Investigation
ut Medical Certifier N Title
f13.0
�✓Cil Address
LW � 6 ui ►7 (.ti"'
Death Certificate Filed District Numb � 2 Register'Number
City, Town or Village ��'�' - is-D 6
❑Burial Date �n C y, tery or rpmatory
❑Entombment Q�� 4�I� U� N e V a ud l,!^°""'e447;1�
Address
`' &emation 0e.,¢40 Zury
Date Placi Removed
2❑Removal and/or Held
and/or
i� Address
I= Hold
O Date Point of
195 ❑Transportation Shipment
O by Common Destination
Mii Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
igiPermit Issued to Registration Number
Iiiii Name of Funeral Hom (,dip L, . Fo l era IA/Pine— oo .c/
7
Address 7
aCktrOVn y
� ma . /��
Name of Funeral Firm Making Disposition or to Whom
14: Remains are Shipped, If Other than Above
• Address
Ill
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Qk, -7-✓-n//Registrar of Vital Statis ics Pam- Q
(signature)
District Number I 510 3 Place )- j\-177 •
.>;.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.W• Date of Disposition $/28//'4 Place of Disposition (i/.tw C�.4vr'.--
2 (address)
Ott
CC (section) _ (lot number) (grave number)
0
Name of Sexton or Person in Charge of Premises r.�f k� an
Z I.
please print)
41
Signature (,C� Title Ll' '►iffo4
(over)
DOH-1555 (02/2004)