Benoit, Leon 1 jt).L.
NEW YORK STATE DEPARTMENT OF HEALTH %tea
Vital Records Section Burial - Transit P - rmit
Name First J Middle A Last p Sex(_, e 0 i\ r Dc'o Al.Le-.
Date of Death / Age If Veteran of U.S. Armed Forces,
c a Y /›+0,3 /� War or Dates
'I . P - - of Death !« Hospital, Institution or,
9100 own or Village �„s-�� it r Street Address c'k- fct Ohs 1.-rio
t ,anner of Death LN Natural Cause 0 Accident 0 Homicide Suicide Undetermined' Pending
W. Circumstances Investigation
tij Medical Certifier Name Title
5G4- "r- 4;0.sc ; __ fri.j -
Address
F(-(ems i 100 ftto( Y�-, ‘Le,-i'( s, M,`,. /- 30(
th Certificate Filed V District Number Register Number
C� , Town or Village �Le,s -h 1V . 60 ( Tarr
11 Burial Date Cemetery or Cremator11
0Entombment - S/v2 //- ,tit ct/;c_� .'Cr+44"a!�
Adu`i ess
I'Cremation (u,G.z../5bs-kd .N� `Yct�
Date ( Place Removed
Removal and/or Held
and/or Address
ht Hold
Ca
0 Date Point of
ft El
Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iiiii
Mi
:: Reinterment Date Cemetery Address
Permit Issued to � .� Registration Number
Name of Funeral Home 4 s More / u Aer--( f t'"'"e j "..1,,c, p®'-fryr e
Address
7 cS(el,"^ fie , �.-, ' Ia ixz _
<' Name of Funeral Firm Making Disposition or to Whom
}► Remains are Shipped, If Other than Above
Address •
i
Permission is hereby ranted to dispose of the human remains described above as indicated.
>' Date Issued Al I Registrar of Vital Statistics (pkA,�i--,2 LA)��,.
(signature)
District Number 5"60 ( Place g 1 .s �� \\ S/ N U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 5/2}5I(3 Place of Disposition gU;,.., Cy+-r dt',r..
2 _"(address)
w
tfl
CCr
(section) (lot n tuber) (grave number)
Name of Sexton or Person i Charge of Premi s >� PyM
lt
2 (ple se print)
Signature aril—
l— Title t' MI4� ,
Vi (over)
DOH-1555 (02/2004)