Butler, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _ _ Burial - Transit Permit
• S Name First Middle I ast 1 Se>M
:_ .bey_ Cdwtht;�-� Y
<= Date of Death Age I If Veteran of U.S. Armed Farces,
i 1s] o i l ���' War or Da s.,� i s ( mi s s
"`' ce of Death i Hospit lnstitutior
..: City Town or Village 1o,i5Q•-, ►� RPh
Street Address
Manner of Death ka Natural Cause Accident i t Homicide n Suicide n Undetermined Pending
Circumstances Investigation
lig Medical Certifier Name Title
43
any el B, fill I ors MD
Address rot oI i A1Ska ( Ina goad , Albany, la
::.: 1 J Q f, NY n
Sri: Death Certificate Filed ` ! District Number
:' '�' City a A I b o ( Register Number
F �1CityJ$own or Village �/ 1 d � � �� �
(�1 Date ( i*7 I Ce etery or Crematory
I !Burial 2.-1 —` 1 ? `licap V :euJ CYOmcc +r
Address 1 �+ ,
Cremation C ue�ensbtkry _ `i
2❑Removal Date Place Removed
and/or and/or Held
Hold Address
0 ! Date -- - :- of
N Q Transportation
_ j Shipment
isby Common Destination
Carrier
::.:- 0 Disinterment Date E Cemetery Address
Date
ri Reinterment Cemetery Address
. Permit Issued to _
Name of Funeral Home Eaker ( Registration Number
Address �ultelCc/ flume_ it
1/ LCC{a y ette a , C t,tC,LnSbLt,r ; /Ue w VoriL 1 a gc4.1"
<, Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
1 " Address
E
Permission is hereby granted to dispose of the human rema" de rill -. • as indicated.
Date issued 2r-1 5—17 Registrar of Vital Statistics ,
(signature)
gg District Number 101 Place Cis— Of Albany
I certify that the remains of the decedent identified above were dispos
ed of in accordance with this permit on:
6 Date of Disposition g/n in Place of Disposition ' V t
(address)ILI
� �.. Arti
>n
Name of Sexton or Person in Charge of Premises (section) lot number] (grave number)
... �r ~'�
L Signature fe,..-
2 (please print)
Joct Title ittAri.r.
(over)
DOH-1555 (9/98)