St. Andrew, Zane 4 Fd- De. 4- # Z17
NEW PORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First 2a�� Middle L st ex
S rem
Date of Death Age If Veteran of U.S. Armed Forces,
31 I 1 20 22 ,D* (z-k War or Dates
▪ Place of Death Hospital, Institutio r
t 1 r
City, Town or Village 0. l Street Address p� Ha
Manner of Death Natural Cau Accide Homicide Suicide Und rmined Pending
Circumstances Investigation
in Medical Certifier Name co. Title
A rnOSIQr i\A
Address Hacp1471.)
rYgam c � � l�JDeath Certificate File• Q- District mbergister Number "
; j City, Town or Village ' . rl I OIL 2.
OBurial Date3) a.4 C ter y or Cremato
❑Entombment2U1 QreWI �
Address t_
'�remation Q,�R.Q.Q.VLSp
Date Place Removed
❑Removal and/or Held
�="'
and/Holdor Address
8 Date Point of
❑
Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Re istration Number
Name of Funeral Home t OfE r(4ktQ 4/44....e_ 00 Li
Address -1 at)rman A-vt, i,Coyid-h 1 j /2822Name of Funeral Firm Making Disposition or tohom
Remains are Shipped, If Other than Above
;'; Address
CC
tU
r` Permission is h reb granted to dispose of the human remains esc ' d abc as' di ted.
Date Issued 2022 Registrar of Vital Statistics R•�-- 1,
(signature)
District Number 1166/ Place Sa k-ajoy,_
9prii �1 Ai.
I certify that the remains of the decedent identified above were disposed of in accordance withh thisth permit on:
p ' Place of Disposition —F4AL .C%/L-�
I�• Date of Disposition 3 to�ZZ P
W (address)
Ca
11 (section) (lot ber) (grave number)
0
in Name of Sexton or Person in Charge of Premises tApi L w4/1/
(please pri F
lifSignature l Title rir��9
(over)
DOH-1555 (02/2004)
585E
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
•• e View Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License#