Kolinski, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Firs Middle Last Sex
:jrn
rna bDate of D athLTHo
eteran of U.S. Armed Forces,
ar or DatesPlace of Death 1spital, Institution orJ �^ nCity, ow or Villageeet Address OT,U uGC
Manner of Death Q atural Cause ❑Acci ent ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
S M r44-9. ICI
Death Certificate Filed District Number Register Number
City, Town or Village Malta 4560 �O
Date _ Ce etery or Crematory
El Burial d 9 /p f vt" erem u.. �
Address
<: .Cremation
Date Place Removed
Z❑Removal and/or Held
-- and/or Address
Hold
Q Date Point of
N ❑Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homei YY1 3- fiSr" rah Tim 0A051
Address \'
AOt.� f o act cc9 �Q�Q Gi_ ►1 5 p `o-t ) (p(�
Name of Funeral Firm Making Dispositi n or to Whom
Remains are Shipped, If Other than Above
Address
. Permission is hereby granted to dispose of the human remains described above as ind' ated.
Date Issued 1 b 13 11 119 Registrar of Vital Statistics A'vs
(signature)
District Number
4560 Place 2540 Rt. 9 , Malta, New York 12020
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LZ Date of Disposition 4 Place of Disposition pirt/e- to o� C r e—/n a-T4i*P
(address)
LU
t/J
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises M 1'Cj#eZ
(please print)
Signature
1Title cre �Tit�► /
(over)
DOH-1555 (9/98)