Osolin, John NEW YORK STATE DEPARTMENT OF HEALTH
it 1
32
Vital Records Section Burial - Transit Permit
Name�.1 �/� i
Middle � L�t � Se/�f
,ia
Date of Death l� Age If Veteran of U.S. Armed Forces,
TO72+2 ) d,0 7 War or Dates /,s"2 — / ,��
P e of Death /� / Hospital, InstitutionN� 1��/� Tli
ity, own or Village /( JA !/� Street Address -f ; d,� 1
141;r nner of Death Larimri atural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Nam r ;17/Ni(c5
GI �iGf�ee /4�Aiof
7 cr ram- fi/ ati_ ,T, ..(/.7. /M a
Death Certificate Filed �� District Number / Register Number
i Town or Village��� J r(,p/�_f- �d7 31
Burial Date / Ceiri tar qr Cremator
❑Entombment Address
� rremation �c -e---1 ,/: d?( /-62-4-2_7--Z 6,,L!s " ,. •
Date Place Removed /
Z I—I❑Removal and/or Held
and/or Address
Hold
0 Date Point of
to)❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
gi
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Hom2/I014 j#(_ 1(0 p7,-/ n c - `j / ' '
Address i/--e, ._ / ` ���_a_r lam,/G),/7 . v/ J)- 7
Name o Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address .
.
fl"` Permission is hereby granted to dispose of the human remains descri e/d above in ' t d.
IDate Issued 6/1 a/ y Registrar of Vital Statistics /�%c�
( ignature)
District Number �(a7 Place C ! ! 7 (/ 77f � /�( g
7
16.,-,,;,•:.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Place of Dispositionf 4401(� C 'tor,urt,
Date of Disposition b 121�12 '
2 (address)
UI
Cl)
CC (section) A (lot number) (grave number)
Name of Sexton or Pelson in Charg of Premises trfr,p{J4 Jehe4{4
2 / (please print)
I Signature A t,— Title Olt nATM-
(over)
DOH-1555 (02/2004)