Monica, Morris NEW YORK STATE DEPARTMENT OF HEALTH
• ! # (XL
Vital Records Section Burial - Transit Permit
Name First Middle A Last Sex
VIA dvtik i s- /1/1 1,4 1 6-6k, Ai.de_.
Date of Death Age If Veteran of U.S. Armed Forces,
1 / .A 6 UU/a,D i Z 6 5--- War or Dates —
f-L.4.
P. of Death -t- Hospital, Institution or
ity, own or Village (9 L.�s T �15! Street Address t/9 Lc - f �� 'gf
nner of Death qNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined �I�I Pending
tlt Circumstances 111 vUu Investigation
W Medical Certifier Name J[ Title
d I A�.L 1�KL Mo�.L /frp,.
Address L)Lt1, ,Il., 1.4„. .` ( 0 x QK I 6'(,, -�_., -i, N, /); O i
«,..B6alf ertificate Fd( - ) District Number , Register Number
r' it wn or Village (9 Le4, ---a. 1 >'- S 6 1-1 S-9 3
❑Burial Date Cemetery or Crematory
['EntombmentI D.b,j3 1 a 3(2---• ;',1 e V P e ,.a 6•.,..17-{�r y
Address
iq WCremation () e&S b,r ) ,kJ 2.' l orK
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
IA Hold
0 Date Point of
oi❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home L,t S m,rc t ,1 e!'- ( H. „...„, ,..).„ coo-"fir
Address 7 ,,
ei',A, 4 v C r rqq, , i� �a
/
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;; Address
tr
ttt
"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1;Z/a 7 ��of)....-Registrar of Vital Statistics tJ c—),ro ✓,
(signature)
District Number 5 b01 Place 6s `\S N u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
al Date of Disposition it.-31-t2 Place of Disposition -f UN Coi-efixio•--
a • (address)
iii
ta
IC (section) (lot nurrayer) (grave number)
Name of Sexton or Person in Charge f Premises Arsky, ,Qar-ei}'
z (please print)
• Signature Title Ceerti e
(over)
DOH-1555 (02/2004)