Ryan, Mark NEW YORK STATE DEPARTMENT OF HEALTH tt 1 q
Vital Records Section % Burial - Transit Permit
Name First addle Last Alex
.,,,E:iiEE: 7 gR4 n l MALE
' Date of Death/ Age If Veteran of U Qte9/11
rmed Forces,
:_::> War or Dates
Place of Death s Hospital, Institution o
City, Town or Village 6?4tA t"AtLS Street Address /,,Cats , kigi(1' fr/OcP/719 L
Manner of Death p Natural Cause ❑Accident D Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
/7 RIR 69 , Vvwi il kis: PI.
' Address
/60 PARk SS.7" 6 n-5 rwas N /ow /
gi Death Certificate Filed District Number Register ber
iiii City,Town or Village 6AEA.S i--i4t.L S (c-A 61 1t�j
><.[]Burial Date/2/ / ery or Crematory
% �a v%� Ct �/ View C RE M9 76 a i 44 r—(
: []Erdonbment Address(Cremation c //�� ��
/ ( Ake"( "Pc9Ai0 ( S3e: j /02(f19
for
DateAddress Place Removed / y
0 Removal , and/or Held
Hold
Date Point of
jQ Transportation Shipment -
t by Common Destination
Carrier
•
il
='0 Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
=_` Permit issued to Registratiopllumber
IgE Name of Funeral Home AQA(rf- A(Nixie /ii• S—
<' Address .
/ GJA->' PE.J 6-.4,E/us a V. /dee/
is Name of Funeral Firm Making Disposition or to Whom
ii4 Remains are Shipped, if Other than Above
NI Address
a
Permission is hereby granted to dispose of the human remains described above as i .
<` Date Issued Qy /A3410/L Registrar of Vital StatisticsA.)/(4-/—
/.; v d
_ (signature)
-'< District Number 5 k 0/ PlF!fiiace /2- /I)y'
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ut Date of Disposition q it)ll Z Place of Disposition Rt U,Qy Ck,ri,,,`
(address)
ILI
44
IS (section) �/ (lot n ber) (grave number)
#. Name of Sexton or Person in Ch of Premises G 4a1' r' J Ow*
(please print)
::<:; Signature �� Ohre of
9Tale I
(over)
DOH-1555 (02/2004)