Durkee, Marvin I . ii51
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
„nAKI/V 6./II�f zjc,,r e me-' le--'
Date of Death Age If Veteran of U.S. Armed Forces,
.! c� _ � 2 War or Dates / t�
}- Place of Death l !,
// 5 Hospital, Institution or
W City own r VillageZ i41:1 d/ Street Address/ iQ 9
a Mann Death atural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LU Circumstances Investigation
Ili Medical Certifier Name Title -�
ti c7;h 1 S .Gil.4 (. .rq /�l/
Address / //` / ,Si ^l f F
Death Certificate Filed District Number Registerumber
City, r Village i,.,/X',`fe ,(j 5-� �6
>:: ❑BunaT Date Cemetery or Crem tory
['Entombmentr _�� f ,1-? Ve v./ 61-KL�v✓!.Av/C3>/
Address � y
Cremation CY . Je-/' /l ;,,, ,, Qi,ee4.5i.iA,r-/ Jl I o�CFe,
Date Place Removed
Z ❑Removal and/or Held
and/or Address
1.. Hold
0 Date Point of
a 0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ��//ff �/j y� Registration Number
Name of Funeral Home /'�"/Gb vl Gj-- ,/9 ,K���e f 62/730
Address/ / /) / /
/ 2 e, it
,.„,:,:i, �L�oL��. Ye!. a,,, ,e,.„(, ,,,,,/i/
Name of Funeral Fare(Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
I
Lu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/C Q 1 )0 Registrar of Vital Statistics a- Itrik.k,WA-
(signature)
District Number 5ilXip Place t ,-�� halk )11-Qt0 4 "
I certify that the remains of the decedent identified above were disposed Cf in accordance with this permit on:
Z
111 Date of Disposition 11410 Place of Disposition emu., roc "--
(address)
ILEA
ta
CC (section) ...4t numbe (grave number)
0 Name of Sexton or Person . Charge of Premises t'A} r evI,�n
ease print)
III Signature Title lint'
(over)
DOH-1555 (02/2004)