Loading...
Russell, Richard NEW YORK STATE DEPARTMENT OF HEALTH - 1 Ci Vital Records Section - _ « Burial - Transit Permit si Name First idle Last Se Al igg Date of Death Age If Veteran of U.S. Armed Forces, :1 14 4 (- ©1,, 7 X War or Dates /(' i -e t Place • Reath Hospital, Institution or ,j 1 -:f City, own •r Village 0 ITT€Ai Street Address ;6 o(/er l4; If/2,4 d OD L/ `- Mann of Death E4 Natural Cause El Accident El Homicide El Suicide ri Undetermined ri Pending a Circumstances Investigation Medical Certifier Nam Title : Dr/itmi Sy,eA if M IJ :< Address :l: Fel.T A' lie tittrh C e 1i 1 e Sc,— 75o 1 To 1%, Akv're k I 19 :``. Death ertificate Filed District Number Register Number }-.-,::i City own r Village Lef Tve`f ' Date or Crematory : ❑Burial Mieiti I I - O b j %ic/e(?} •t) Address._Cremationue �N$`6u('"LJ, New br�C Date / Place Removed 0❑Removal and/or Held i and/or Address a Hold Date Point of gEl Transportation Shipment by Common Destination Carrier :: Disinterment Date Cemetery Address Reinterment Date Cemetery Address i Permit Issued to Registration Number ii. Name of Funeral Home flp y j 4R,K Rprot F &u,-r. AN 0119 y f ' Address i If tg-Poycrrip-- -7-L. 0 06z.-"ks is on-a itly /2T-0 1/- i. Name of Funeral Fjrm Making Disposition or to Whom ' - Remains are Shipped, If Other than Above Address 2 ii Permission is hereby granted to dispose of the human rem ins described above as i icated. Date Issued S /--- :(o Registrar of Vital Statistics arlijat D o LA : .v- 59 >f , / �7��VL (si nature) 0District Number ls7 Place O I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iii Date of Disposition 5/3/bb Place of Disposition Pin.r‘it.e.-/ Ci'cn fur 2 (address) / W t) (section) Cl • (lot number) (grave number) Name of Sexton or Person in Charge of Premises h f S St n n t It // (please print) 44 Signature (,A- AA__ Title &c' ' t 10 (over) DOH-1555 (9/98)