Latham, Robert s-ga
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section \ Burial - Transit Permit
Name First
Al
NJicidle `+ h4IRt Sex
Date of Death / Age If Veteran of U.S. Armed Forces
A /ay D G r War or Dates /l V 3-/rH6
}- Place of Death Hospital, Institution or /�,Y,, /i
City, Town or Village , 7.epvv A//S Street Address /' u9 0Q/ £s
a Manner of Death Z Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ri❑Pending
W Circumstances Investigation
tii Medical Certifier Name �/ / Title
/ .(4/d/C , 5 do ; /;1- )1).
Address
/v 67, /.ep� , i// �Y
Death Certificate Filed / District Number Regis r Number
'/e-
City, Town or Village ,,� �/ ,.-C.0/ Oi 2
❑Burial Date ` Cemetery or Cr atory ./
['EntombmentAddress / /2�/ e- U c-g-t) a-e7
remation (jL' `SbtlXi7 , ,t-)`y / d�"
Date Place Removed
0 ❑Removal and/or Held
and/or
Address
N
Hold
0 Date Point of
pi Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / `// Registration Number
Name of Funeral Home L/9ri/C/ -ri4,�/ i'idm.�- C56 2^13
Address �f 0 // t' Q . 6k- 0 4.`b 5 /4-467_ 474 A)
Name of Funeral Firm Making Disposition or toWhom / 3,
Remains are Shipped, If Other than Above
a Address
it
C' Permission is hereby granted to dispose of the human remains describe Sabovj as' is
Date Issued /2 2(v`D 6 Registrar of Vital Statistics ✓�
(signature)
District Number t j 6O/ Place j ).o /1/5 AY
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ttt Date of Disposition 0IJKA Place of Disposition 4)in2,I; - C.-w' G r
(addvr1
ress)
ill
CC (section) 1/�G r�S C (lot number) (grave number)
J
12 Name of Sexton or Person in harge of Premises 1 e 4 (.04_
.2 jiLi (please print)
Signature C Title C- c, kr
(over)
DOH-1555 (02/2004)