Siadik, Stephen fl
NEW YORK STATE DEPARTMENT OF HEALTH LI ID
Vital Records Section , N Burial - Transit Permit
>; Name First (� Middle (—L.ast Sex
J 7-6--Pii2�-3 ; nvi,9�- c/92)/ K 002-c-4"
Date of Death Age If Veteran of U.S.Armed Forces, j -.ii-
PtJ/ 43 )i 3 '7 War or Dates 6 S ()jJJ ,.J.J o . ) �3
... Pia - -' II-.1 {�Irkl tttutlon or
C ,Town •r Village R p t. ,J Street Addr 3 T//7 co byL.
CI M • De Natural Cause Accident 111 Homicide ❑Suicide ❑Undetermined Pending
41 Circumstances Investigation
iii Medical Certifier Name /yZ/C �7U7�i=s`r/a.J Title
/ ft�J
Address I /� (�
/0 2 / ,C Jr. C(.tr;)3 F c.1 ./ )
giii Death to Filed District Number /` " F i Z('6 ster Numbe
<` a ,Town Village L. Ul U 1
Burial Date9/2-0 //3 Cemetery Crematory
1 ,A)es- ?)/ el--3
Address
_- remation C, (MY(- Q 0 b���-S-E
Date Place Removed `�
0 Removal and/or Held
and/or Address
Hold
Date Point of
liQ Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
3
El Rein#ernent Date Cemetery Address
iiiii:::=` Permit Issued to Registration Number
Name of Funeral Home Hal nofd ','6ci)(er Fu ne«.( Nt)(7 of I lQ
Address 111.1 La-1ca.ye+4e- Styect ) C�tteensbu.sy # NevJ1 Vol-
or- k 1a %oy
ligiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remai described a as indi ted.
iII,i: Date Issued Q(F a 0-2 a/ iegistrar of Vital Statistics (signature) p 6i S/at'/3ae-__
District Number 5Z'..93 Place 6 O C TU /y 1 nV 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
In• Date of Disposition I1 it It' Place of Disposition £LL Ca„
M (address)
(section) number) 14-
S (grave number)
• Name of Sexton or Pers in Charge Premises «��c{�� "�
(pleas1�
Signature Tille Ctt7Cde
(over)
DOH-1555 (02/2004)