Pitkin, Ronald 3(.
NEW YORK STATE DEPARTMENT OF HEALTH fi • (-)
Vital Records Section Burial - Transit Permit
Name -rst Middle 0 list Sex
qi Date of eath Age If Veteran of U.S. Armed Forces,
dC?'- l b _ o 6 War or Dates /fs53 — / 79/
ifs;:- Place • 'e.th Hospital, Institution or
City, own ''r Village I%%CoNr_(e '.q Street Address l'i 5"
a Manner of Death❑ Natural Cause 6 -ccident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
_tit
Circumstances Investigation
w Medical Certifier Name �/ Title
CI CP, IY'AJl1GLJ' aid r�� a�,0
Address
Po G o l 76J A A /fie_ PIA cial AV 1.2 9'9 G
Death ificate File District N Register N ber
City, ow r Village�IicaAJ'ert p� umber
Date / C ete or Crematory
❑E Entombment 08 /I - �-OYI‘ �I/n' ' j-€iri?A7;^/
Address
MrCremation �Ue.eAJ}4i e M y
Date Plac Removed
Z Removal and/or Held
4 ❑and/or -
Address
ti Hold
trif
Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to �' Registration Number
Name of Funeral Home C�r-toku-J 1..• el* rt.,Gt-At t_ Q a1/45e-g f+
Address j
C-4,V-00
iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
#t
L
P` Permission is hereby granted to dispose of the human remains escribed a ve as "Cl ated.
Date Issued Of-/rf- 6 Registrar of Vital Statistics /� /Crj�J L, 1��1
/ f l (sig at,* /
District Number ` �/ Place -� LQQ,---zip /o. +
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition /I? f(G Place of Disposition Prn.Vitt/ r!rer~crl vt'r,,...
(address)
LU
CC (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises CI e,s Senn-col-
2
(please print)
ILI
Signature (J/t 2Title Ctf e,t�r
(over)
DOH-1555 (02/2004)