Naycor, Sr. Paul 311
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Amiwasift
s > Name First Middle Last Sex
• I- 9-0 L #630 /U c.erre_ S2 . ./yam
Date of Death Age 'v If Veteran of U.S ed Forc ,
(� // 2_ �(„ War or Dates Ag
a of Death �LE3 osPital> titution Su, ��S
City, own or Village ( (' .Js na,,,� ee ddress vL,, s
anner of Death a Natural Cause 0 Accident El Homicide Q Suicide ri Undetermined n Pending
Circumstances Investigation
IAA Medical Certifier Name Title
i Fi2 C.
A) &S /Jv tL1A.)C.0-L.
Address / 6/ C J2 j , Q U ,/S a /moo'Certificate Filed [strict Number Uister r
City, T wn or Villagee Obe. /`e-j,J 60 6
:10 CI-Burial Date f
Cemetery o Cremato
/2_6 i z_ r/„J tr. aks.-1.
,0 Entombment Address
Cremation Q t 44 (3.-L- G 0-awAL A
Date Pla�e Removed
❑
Removal and/or Held
#=" and/Holdor Address
07 Date Point of
Q Transportation Shipment
E by Common Destination
Carrier
_`'Q Disinterment Date Cemetery Address
: — Date Cemetery Address
Q Reinterment
s.
>= Permit Issued to Registration_Number
iiiii Name of Funeral Home VA c y n of d , €c ker Vw ier o 1 (r— 0) 13 0 _.
< Address
iiiiiiiii 11 La- ye.Ale_ SA-. , Q u_eens r y , N e v._i `/oT k 12 B C)y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Permission is hereby granted to dispose of the human remains described above as indi ed.
al Date Issued 6/i q//Z Registrar of Vital Statistics 1,J)0,.A.p ll 3,
(signatur
'' � District Number 560 ( Place e LcZ.M s 1>1 i t/ v
4...::1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Place of Disposition 'g'4Uuv ( .r,orw�
Date of Disposition (,I?0�11. I�
(address)
LI
r (section) I - (lot number) (grave number)
Q Name of Sexton or Pe on in Charge of remises / 'Tilli I' SIN -
ease print)
f Signature ,,L.d Title CIA4 4:rO'C
(over)
DOH-1555 (02/2004)