Newberry, Roger NEW YORK STATE DEPARTMENT OF,, aEP IH 4 /,'' `�
Vital Records Section tmoilmeBurial - Transit Permit
Name first MiddleLast Sex
i a_y — IA)
e� rja_A,.6��-r-y 7
Date of Death Age If Veteran of U.S. Armed Forces',
`''' !v t i^%/ p a_ 02oo' O c War or Dates ,41d
l• Place • :-ath Hospital, Institution or _
WCi , Town •r Village /," wd e,._e7p Street Address Olo,ses Gad)Al %c/0 it se,iA
Mann o •eath jgLJatural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
ili1�=� Circumstances Investigation
ili Medical Certifier f`Jame Title
Pc0 (.-;le,ifi eh,,,,„Ai 7?-b0
�0,4
'�Address ,�f ..
a. q f IGONd0 Ye/g
/3 /U? / a 3
Deat .ficate Filed District Number Register Number
City, own r Village 1 1 CU h,cle-,ri y A `. - y go
i:i> ❑Burial Date C etery9r Crematory
❑Entombment d�/a3!/dal "' 'Lie_ 0e:i) erG.s4,A l or.�/'
Addre
remation �V v e-e&1.5 6 cite N
Date Place Removed
4❑Removal and/or Held
and/or Address
F_- Hold
CD
0 Date Point of
fZ' Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 2do p ;-d, e.l� roAie rp j A/ e Or-5'02?
Address / ``�. /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
lLI
P" Permission is hereby granted to dispose of the human rema- s escribed above s i dicated.
Date Issued y/,2y7,2-Q,( Registrar of Vital Statistics ,/ /,' ` 2 y 01
(si ture)
District Number 15-1 Place 1 I CC A,c(e Ya A A '
9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
U.I Date of Disposition 4-Zy U(e Place of Disposition P/n(E:pi- ( It) _1 m' 1-C12► 0/11,
(address)
iii
Cil
CC (section) (lot number) (grave number)
ct Name of Sexton or Person in Charge of Premises G .\"L'- r�
z (please print)
Signature C 11�G�� ! Title C. R =1^43--cal L
(over)
DOH-1555 (02/2004)