Malcolm, Robert 4
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
g Name First I� Middle ` Las vILS
-b Date of Death A If Veteran of U.S.Armed Forces,
�`3 "� War or Dates iQ43- 19
` Plac- :a-ath Hospital, Institution or `�
.- Ci Town •r Village a_e-e.--ADue- Street Address (Q J.1-.6 Y'i t .,r�°J-c_
.' Mangy"0:171--th'Natural Cause 0 Al-nt El Homicide Q Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name - Title
m Address
1 `-� qf a tA Ds(' l i kes cliik r ►A- `it 4
Death ' cate Fil �I�, � 1, District N tuber (i)egIster mber -
`` s
��' City, own Village� ti`�- ''�
Date Cemetery or Crematory/r.
Burial )77— - mse V i P__L l _.0 fry A-e-r
Address
Cremation � , L x_ , UDate r Plac3_t,t_
e Removed
❑Removal • 1 and/or Held
and/or Address
l Hold
0 Date I Point of
Vim!- 0 Transportation Shipment
a by Common Destination
Carrier
[�Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' Registration Nti tuber
>` Name of Funeral Home cL n�� k� IQ
{> Address
(---4. 8,..e..,,so, , k.\1, I afoy
.--.
t. Name of Funeral Firm Making Dispositio or to Whom J
�'" Remains are Shipped, If Other than A -
Address - -
M
-15.1u' s describe1 Permission is hereby granted to dispose of the human re ' v as d
'II
Date Issued D.4-blo Registrar of Vital Statistics 4..��
Ail
re)
t t ��,
District Number ��S Place
I certify that the remains of the decedent identified al5ove ere disposed of in accordance wi is permit on:
i Date of Disposition 9 L2 7106 Place of Disposition
( ddress)
fa
S. I . #2 86 1'
cc (section) (lot number) (grave number)
flName of Sexton or Person in Charge of Premises M ICHAFL G FN I FR
g J (please print)
l Signature J MM1'.. Title SUPT.
(over)
DOH-1555 (9/98)