Bundrick, Damien F. NEW YORK STATE DEPARTMENT OF HEALTH (0 ,
Vital Records Section Burial - Transit Permit
iv e First Middle Last Sex
►ten 4- PMOKIrLc Ma(e.
Dat of ath LI Age If Veteran of U.S. Armed Forces,r
�I (p�c .D Co (Q War or Dates \I )e +�C� ►�
Plac of ath Hospital, Institution or
1 City, own o Village + lel d le q Street Address 1573 d) \l I I Pending
Manner o1Death Natural Caus Accident Homicide Suicide Undetetmine
Circumstances ❑ Investigation
x' Medical Certifier Name Title
ddress
NyJs.�? Death Certificate Filed �S l District Number Register Number
City ow, r Village ;A )e. e S5 R a
❑Burial Dat J C�etery o Cremato y
['Entombment 1-I 1 Zi 1 ' i nF �C 1,�) �.reyN yy
Add�ess J
Cremation nu c yyc,hw1 u
Date J Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
• Permit Issued to � I ^ Registration Number
Name of Funeral Home ' ;,` �,r r.( l 4 V)k?, I n C Wa- I
Itt Address '� Ch-1 u r C Jt-- La(C U..U,1 Z Lr' rk Ay 12 g -
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
--- Address
Permission is ereby granted to dispose of the human rem ' described above as indicated.
Date Issued I I 2. L Registrar of Vital Statistics ` �n
111
(signature)
District Number -1-551 Place 0►) D F h1oa k iiit
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ,I)ZU/ZI Place of Disposition i a ifi-
(address)
(section) (lot nuunber) (grave number)
Name of Sexton or Persil in Charg f Premises a l' 4v-
t!.../f /�✓" (Please print) � �,y
Title i il�"vi"I"e.
°a Signature
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) ® 4 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#