Bessett, Kevin NEW YORK STATE DEPARTMENT OF HEALTH ti 41 I
Vital Records Section r - Burial - Transit Permit
Name First Middle r� Last Sex
/4 t// d Z- l�e . ,Si e. 2 / '
iEiliil Date of Death Age If Veteran of U.S. Armed Forces, A
Fr _ / a _ '�/3 War or Dates N Li
Place of Death Hospital, Institution or /
City, Town or Village 3 c,Ll I--C/'-Q 1J Street Address 3 ? CI ' (-M. 1-0 o&i
W.• Manner of Death ,�% Undetermined Pending
ilj �� Natural Cause ❑Accident El ❑Suicide ❑ ❑
Circumstances Investigation
itl Medical Certifier ame Title
AA . —Si0c)T LJ bpit- \
A dress
0,2 A r, ' %t�-e---T 61.eiv c, /i/s ) Y . /` /7/
Death Certificate Filed District Number Register Number
Ziiii City, Town or Village e ®je I }-D . C—' 4#
❑Burial Date e ` Cemetery(� or Crematory
=`['Entombment Address
_/3 c?e (� PiAuLui l:t-Pirha rit- �f
Address LL
igii Cremation QI,)BQt i ,.0 LA--r AJ ,
Date Place Removed
2 ❑Removal and/or. Held
and/or Address
...,I Hold
Hold
V
c l Date Point of
• Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to '/// ,,--' Registration Number
:< Name of Funeral Home &JA1--A 4 . K/y F`ixe rr-4/ j/� ,,,_ Cti-c77
iiiYi Address
3 al^efeAA A,A N-7. /-' , e -7d
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'; Address
1
tEE
P' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued oSt-Lg.A9i_3 Registrar of Vital Statistics .. . Lt...c)c �Z-.
signature)
District Number j 3 Place C_.2 /L..j(",
<! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition ghri p Place of Disposition ,t' ¢h) �iin-�G d�---
I)
Z. (address)
flit
CC (section) n - (lot number) (grave number)
Ci Name of Sexton or Pers in Charg of Premises I,a �I its
Z. 1(please print)
LIA `�
IL
iiie Signature Title CakezA Art(L
(over)
DOH-1555 (02/2004)