Jarrosiak, Philip NEW YORK STATE DEPARTMENT OF HEALTH ,� to 0
Vital Records Section 1 Burial - i ransit Permit
t Name Fi i % 1t Middle p iit), AlQuo )a Sex
1. Date of Death h Age If Veteran of U.S. Armed orces,
I 01 1 7 3 War or Dates
1 titution or
!Arseof Death C'4 ns i
Town or Village 6,�,ir1� Fa I. (5 Street Address C31 e4<`� C. l5 HO i
Manner of focal Cause Accident Homicide Suicide Undetermined Pending
❑ ❑ ❑ ❑Circumstances Investigation
Medical Certifier Name Title D
.R Na4 e\ A • S\66ei vn
Address
VDD podt Sir eel- Gw\s. ect\1s M'/ 12-80)
}pi, Death Certificate Filed District Number Register um
City,Town or Village Dl/ o
47(
Date Cemetery r
Li Burial \1 1C711 20\3 i(Lc Ut e0
Address i
;i Ei Cremation G u a L . (l.tee mj l�u t, A.L . I 2 -c V
Date Place Removed
6❑Removal 1 and/or Held
and/or Address
Hold
Date
point of
0Transportation Shipment
a' by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Renterment Date Cemetery Address
. Permit Issued to Registration Number
Name of Funeral Home f L-kr fl t rC� b ker Fw,er me_ i 01 J 30
Address `/ Lafaio,tte 331". , 0 tAkulsitx,t'j r A i-/vrk /g?�oy
Name of Funeral Firm Making Disposition or to Whom
'x- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the humarremai descri above . rindi - •.
Date Issued/1 ) ,,- Q/ Registrar of Vital Statistics L ., • '4 ,i_e
x, (si nature)
# District Number c5Z2C)/ Place _gli A-22- Al GI certify that the remains of the decedent identified above were disposed of in.accor with this permit on:
i �
Z Date of Disposition II AO Place of Disposition 't�n'��+� rfd�r�..
(address)
iuu
CR
(section) "lot npmber) (grave number)
' Name of Sexton or Person in Charge of Premises �'rr6+ I4cc JnnAdi
A (please print) 1
1! Signature YL-r Title ac In13T0i.
(over)
DOH-1555 (9/98)