McDonough, Ann NEW YORK STATE DEPARTMENT OF HEALTH 1.9j
Burial - Transit Permit
Vital Records Section
Name First
A , Middle Last, {
� Sex,,-
rlii fant_, C- a inGu P a k
Date of Deat/ Age Veteran of U.S. Armed Forces,
LIiglj 3 _-_ __ _ /L ' War or Dates
i-- P . e of Death f +despitaF, Institutio' or
W - - - C/_ � C US _ 3t,eel.Ad , jirt7)0 p anner of Deatt,M Natural Cause Accident 0 Homicide Suicide Undetermined Pending
W t'�`''�. Circumstances Investigation
LuMedical Certifier Name: i. Title r ,r�
a alrtcic- �cuea-- __ ►~'
Address y oc s n�l P7t.ir.) Gloti
e. )r 0..„t ��Jt,�.ri��: } /
...th Certificate Filed -> .— Dts r; l�umbc Register Number --
T' - - Cileruofo . i ��- �
OBurial Date Cemetery or C atory
av►3 ring. ►el.° Cl efria-O2i
❑Entombment Address -I' nR' �J^ +
remation ( C7�.12�f &Of
Date Place Remo
Z❑Removal and/or Held
and/or Address
MEZ Hold
0 Date Point of
N Q Transportation Shipment
In by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 1i 0,y nal d _ , (jamkey Fu_nef-0.1 -fib01130
Address -_ --
L ak y k. +1 e. SA. , C;)u..e enSbu r v , ti e v,„ `yor k_ 12 t,-?0,-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 AddressiX
a Permission is hereby granted to dispose of the human e ains described above as indicated.
Date Issued L1 l W ick- Registrar of Vital Statistics C nau tt
(sigre) 1,
District Numbe Place �(...„_/...., a ..g C... uLsi_p_r\Ricy
2 I certify that the remains of the decedent identified above were disposed of in accordance h thi permit on:
til Date of Disposition 4-3613 Place of Disposition R=+ (�
t,U +w•c 0r
Ill
(address)
0
it (section) (lot number) (grave number)
0 Name of Sexton or Per n in Charge f Premises titit.., J t
oal-
Z ( se print)
iW Signature —_ _ Title Ca' i4t*
(over)
DOH-1555 (02/2004)