Lewandowski, Adam NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First �"l Middlel
_ Last �Z.
Date of Death Age ,/ If Veteran o U.S. Armed Fames,
War or Dates Uj UJ-1. —��S
Place of Death � ,�f Hospital, Institution or
City, Town or Village ti c�=` Street Address `T
Manner of Death Lj]Natural Cause Accident Homicide Suicide F Undetermined ElPen Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed r District N mb r Register Number
City, Town or Village
Date Ce ery or matory
❑Burial
Address
[�remation
Date P e Removes
Z ❑Removal and/or Held
.- and/or Address
Hold
>
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
L,L
Name of Funeral Home .
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
>` Permission is her y,granted to dispose of the human re ins described above as indicated.
Date Issued Registrar of Vital Statistics
(signature `� l
[ District Number 5 Place
I certify that the remains of the decedent identified above were disposed of in accorh'nce with this permit on:
f- c� c� y �/�
W.W. Date of Disposition a' l'"! Place of Disposition I�1���
/- �Iv /oa—yt) ►
(address)
Uj
(section) lot umber), J (grave number)
0 Name of Sexto or Person in Charge of Premises E-z74& D
ease print) [
Signature (pl Title 7"
DOH-1555 (10/89) p. 1 of 2 VS-61