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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last So
C./.( i:kt-
Date of Death ---) i Age : If Veteran of U.S. Armed Forces,
07_'\I-\ ?..07. ' 0
I War or Dates
i 4-)e of Death , 1 Fiospital, Institution or
Town or Village e WW,sk"\ 1 Stret Address .\\KI3,1-\.1.1.\k.Q... ‘cci..,\. C...__Q.1\\
anner of Death fa Natural Cau Accident L__Homicide 0 Suicide ndetermined 7 Pending
Circumstances "4 Investigation
ILI Medical Certifier Name.— Title
P Y\(4,\NA \-\\'(\•4-. 1/43(_\'‘ r.&N V\1_
Address
e4h Certificate Filed , District Number I Register Number
Ci ,)Town or Village .. 010 I 1 Irelal
Date 1 Cezeten, orCrematorY
Burial
• nE nin b men —
i•'.;,• "- Cll.- Z2.- -2.o2- .. .),r- V\ k._,
L.j tu - . ,.
l Address
ZCremation
Date ! Place Removed
—1Removal ! and/or Held
and/or Address
Hold
.
Date . Point of
0 Transportation , Shipment
a by Common Destination
Carrier
,....____ „.. _._
T Cemetery Address
•• n Disinterment Date
--- . .
Cemetery Address
Reinterment Date
I
Permit Issued to I Registration Number
Name of Funeral Home M e) K1 I rile+I( furl erw ham& i 0101g
„.. .
Address
0 GlICOL.FalIS.,_NIC 'JOY 12103
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Aaai6.--s- -----
a:-
w------- -
13. Permission is hereby granted to dispose of the human ram ins describe boys as indicated.
Date Issued 2) 221 23 Registrar of Vital Statistics
istiratura) t
District Number (DID Place C'' Itk- 0-f A I i I I certify that the remains of the decedentidentifie bove were disposed of in acc rdance, with this permit on:
jlit Date of Disposition 217/,(7_3 Place of Disposition •-1!,AL-•____..
;Address)
Ut
(secar.n.:
i
Name of Sexton or Person in C.; arge of Pren -isse!; _ _ A,,, 1.-
§1 (la!number) 3,,,si
rt (grave number)
2 • ‘,2! ase pint)
W -
Signature e**--- --!--- Title
(over)
DOH-1555 (02/2004)
311
ri E '
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#