Butchino, Ronald r 7 (a -4-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
vi Nam-, First Middle Last Sex
at. ik d . f Middle
-1-c i-h r n 0 Mole,
Date of Death Age If Veteran of U.S.nAimed Forces,
1 Q-- / -a0 / - - 73 War or Dates ( Vv
Place of Peath Hospital, Institution or
City,/T` own br Village in + ,( Street Address (p Mg r ri Ave E.�( I
Manner of Death[2 Natural Cause Accident El Homicide 1=I Suicide El Undetermined Pending
Circumstances Investigation
Medical Certifier c, Name Title
e.e 3( mayKi1,1 kip
Address)
4 Hi 1 WY r- A t) e ( r 1 n+ NV 12$22
• Death Certificate Filed District Vers.);—/ Registe Number
• City, Town or Village /c.
kt❑Burial Date C etery or Crematory
❑Entombment /D_/ 3- Q0 f 7 �e V r P:r.c, .a-e ,y n-l-o y Address
L,I9 Cremation Gut-etb_ L. '
Date 'lace Removed
❑Removal and/or Held
and/or Address
• Hold
Date Point of
Transportation Shipment
by Common Destination
m. Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home "Y c u j r 4 -jyj )--ic)Ka (vie 07) I
Addres
li
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M Permission is hereby granted to dispose of the human remains described above as indicated.
441 Date Issued I 0 13 i 7 Registrar of Vital Statistics 6 ,,_,- ,ti!
Isigna ure
Era District Number y Place 70 ts)n 6i---' 4ad Kal
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition PI jgif7 Place of Disposition i,to L fen ,714 re,,,
(address)
#
(section) dolt"
number) (grave number)
Name of Sexton or Person in Charge of Premiss �1�'►ei
( e print)
Signature 14 T Title fiZkinfilk
(over)
DOH-1555 (02/2004)