St. Andrew, Asher 4 -rei-a. l D 4- # 211
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle ` Lpst t ei.J S Mok
VL � /"t
Date of Death Age If Veteran of .S. Armed Forces,
3I 1 1 2022 _IA k.rT War or Dates
14, Place of Death Hospital, Institution or C,� ,�,
Cityliti , Town or Village A Street Address C_.tJ� 0. ' r/°'mil
Est Manner of Death ixNatural Cause Acci ent ❑Homicide ❑Suicide ❑Undet mined Pending
Circumstances Investigation
al Medical Certifier Name A Title Ivt A `
Hillos C
Address r
rre,
s Ai
Death Certificate File �� � District Number R iste umber 1/4-]
City, Town or Village�Ti...".0
NO;
4[50 I
❑Burial Date Cemetery or Crematory,
❑Entombment22 `PlAtzv 2� re wi k
Address I A r` '
» acremation blU ee,i s r j J\J `1
Date Place Removed
❑Removal and/or Held
and/or Address
i=" Hold
Date Point of
• ❑Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
lii Permit Issued to I Registratio cyumber
Name of Funeral Home )eJ SW lioCe. cuvuz lw _ 00 47
Address _7 ex,,,, ul /- _Q
Name of Funeral Firm Making Disposition or to/Whom
• Remains are Shipped, If Other than Above
;; Address
ill
Permission is hereb granted to dispose of the human remains es�� yd aboy�as 'ndi ted.
Il Date Issued c�J 8 2022 Registrar of Vital Statistics �i%+�—</--ter Ro.--
` (signature)
District Number q56 / Place &(.eaLdiri y/).A S V
,...„:„„„„ I certify that the remains of the decedent identified abo e were disposed of in accordance with this permit on:
ILI• Date of Disposition )1(b t it Place of Disposition
2 (address)
Lu
CC (section) ofi number) (grave number)
• Name of Sexton or Person in Charge of Premises
t- S AN&
z
/� (please rint) /�
Signature // — Title `� �t �
��'""�� (over)
DOH-1555 (02/2004)
ti .
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#