Tiso, Michael NEW YORK STATE DEPARTMENT OF HEALTH t t,'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alel-iA - V T/SCE m
Date of De th Age If Veteran of U.S. Armed Forces, 1 Q-�
/07/67/3 `7 S' War or Dates
Place of Death NL,i'T/fUmf,e4l- JU.D �t� Hospital, Institution or
Z City, Town or Village 1/"v 1 Street Address 1(j (.1.0C,o n J4 1Jr &,() .
Manner of Deatha Natural Cause E Accident ❑Homicide E Suicide ri❑Undetermined ti Pending
Circumstances Investigation
iii Medical Certifier Name Title
0 V-- .S7-0 07-6,1I,r3G/f-CT- �`�
nr Address-1)a:Nr S-Y.() Q-4/ C4,,(-1 `
Death Certificate Filed District Number Register Number
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City, Town or Village Noy4O -' a.n�, L4Gj (03 I0
0Burial Date ( Cemetery or Crematory
❑Entombment I(DI17 Iao �- /7//LG///62i) ex64,178�-`y
Address
;Cremation / 5/2'4-/4i /..,/'
Date Place Removed
Z❑and/or Removal and/or Held
„ Address
Cl)
Hold
0 Date Point of •
i El Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to • Registration Number
Name of Funeral Home ,Z) J?,,Q/2 J' / .2///6/ am f712i?? - 00414 O
Address
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
tr. . -
ILI
IL
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued f 0 4 t ice\ l Registrar of Vital Statistics &,ty L,---b
(sign use)
District Number 14563 Place c $(-. oc `\(0 f 0 \f LX
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition toli�113 Place of Disposition �„4 ,✓ G ,
(address)
ill
tO
CC (section) t number) (grave number)
0 Name of Sexton or Perso in Charge f Premises r,.. SSh,./
Z (pleas print)
14
Si nature tTitle CT' tcl1
f (over)
DOH-1555 (02/2004)