Mc Lean, Roger NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«` This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER IFiCATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. C f/` v`
(L/C/717a--A.2
Town, Vil r Re 's red No.Dist. No. 60/ C Y or City ...
�"�cit , giveA eet
Name of deceased .'a o<� ... Veteran 7. -
(If veteran, give name of War)
Single, married, widowed, /
Sex ,or divorced (write the word) .. . . Date of Death .. G ' ��.
Age Yea Mont Day Birthplace....... . Z46 .CLjy
Cause of Death ,�{ .... h�-- z-�
Certificate was signed by...... M.D.
Address .. Y.
Place of Burr Removal) /
(If body Is to m arily eld pa er
Cemetery ((1� ... . Date of Burial /:) — 6 19 ��
(If body is to be temporarily held, fil in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have c rd it in m oral Rec with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
\'°(1Ve' / ' V__
to ame) (Aaaress}�
the to hold temporarily and ... the body
(Undertakero s
erson havin charge of corpse) (Int ove, her e dis se of (state how))
Dated , 19 7.0--- (Signed)
Lo a1 ReAtar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No, 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
i ;/, ,
Date of` T £ ) ii ram- rz was ' 19
(Interment orusab
l 1
(Name of Cemetery,'Cremirrnri�**
( L'it/A7C/Ke' fi-1-
Section Lot No. -//` Grave No. -
(Signe t ,4( / l 'k •1*,
(Person in Charge)
Address �,. / 74 /-L L�C�--'_.-
Pers n in charge mustreturn his Permit to the Rei rar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.
DISTRICT N ---..)--_'.._..1
REGISTER it
STATE FILE t/- ----------- —_
` STATE OF NEW YORK DEPARTMENT OF HEALTH Sq t-t ..,E)VITAL RECORDS SECTION
MEDICAL/BURIAL DEATH CORRECTION REPORT
. Date of Death Place of
Name of Deceased Death
MONTH DAY YEAR
er420A.BURT REMATION,REMOVAL 120B.PLACE OF BURIAL,C MATION,REMOVAL OR I LOCAOTION `� )
OR OTHER DISPOSITION:(Specify) MONTH DI �f i U t ; �j(City or town and state
(P y) . OTHER DISPOSITION: Fj t 1
r
t� 21A.NAME AND ADDRESS OF FUNERAL HOME: Tv ) .a h ,l JlAzinL 218.REGISTRATION NUMBER*
tC\S :►-1 I CeL1,-•Cut- Q ,->Q I�R7-�,V.J11( C)ICQ� ,
2 •NAM OF FUNERA OIRECTOn:f"' '22 GNATURE OF FUNE L DIRECTOR: V 22C.REGLETRATI N NUMBER:
C� ' r ' vv// f3?
23 .SIONA'rURE OF REGISTRAR 123p.DATE 2 .BURIAL OR REMOVAL.QERMIT ISSUED BY: 12A3.DATE
(� I P\ 1 I I FILED: MONTH DAY'YEAR� /�\ I ISSUED: MONTH DAY YEAR
sL,r , -r • i A ,.. I( R -k eti .v 8 C.L i Da Q
II
ITEMS 25 THROUGH 33 TO B� _ ITEMS 25 THROUGH 33 TO BE
COMI�L�TEb BY CERTIFYING PHYSICIAN,. —on ', COMPLETED BY CORONER OR MEDICAL EXAMINER
.r:
1 25A.TO THE BEST OF‘MY KNOWLEDGE,DEATH OCCURRED AT THE TME,DATE 25A.ON THE BASIS OF EXAMINATION AND/OR INVESTIGATION
AND PLACE AND DUE TO THE CAUSES STATED. f I+ I IN MY OPINION DEATH OCCURRED AT THE TIME,DATE AND n Cr71:::N`"1
SIGNATURE: ( , ki irni DAc' '-VEAA PLACE AND DUE TO THE CAUSES STATED. r;YSE IA s
SIGNATURE MEDICAL
1 J . AND TITLE:R` ❑EXAMINED
6 250.THE PHYSICIAN ATTENDED THE DECEASED-' %1 25C,LUST SEEN ALIVE:J , 258.('RONOUNCED DEAD 25C.HOUR: 25D.DATE SIGNED:
1
y .t l - ) /
MONTH DAY YEAR MONTH DAY' YEAR I -MONTH DAY YEAR j'?MONTH DAY YEAR MONTH DAY YEAR
c roOM TO r- , 01 I `'. I m
25D.NAME OF ATTENDING PHYSICIAN: T', �
1 LICENSE NUMBER 2st:810NA1URn OF CORONER On CORONER'S PHYSICIAN,IF OTHER THAN CERTIFIER:
,, 28.NAME AND ADDRESS OF CERTIFIER: ( ;. . `
•
27.MANNER OF DEATH: UNDETERMINED PEN01149 28.ia1AS CASE REFERRED TO 20A.AUTOPSY?WB,IF YES,WERE FINDINGS USED
? NATURAL CAUSE ACCIDENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION CORONER On MEDICAL EXAMINER? NO YES :TO DETERMINE CAUSE OFO DEATH?
LJ I ❑2 ❑3 ❑4 L-J15 LJ 0 `) i { .. 0 NO U I YES • ❑0 U 1I (-I n NO t J 1 YES
CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLEtING CAUSE.OF DEATH CONFIDENTIAL
30.DEATH WAS CAUSED BY: ENTER ONLY ONE CAUSE PER LINE Fon(A),(0),AND IC). APPROXIMATE INTERVAL
.: BETWEEN ONSET AND DEATH
PART I.IMMEDIATE CAUSE: •I . I : I —
4, (A) I .
1I > I• II
DUE TO OR AS A CONSEQUENCE OF: 1
(p) I
d I
/U DUE TO OTT AS A CONSEQUENCE OF: 1 —T — ---- - -----
G (C)
I
w PART II.OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO
iii DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART 1(A):
31A.IF INJURY,DATE: :How: '31B,LOCALITY:(City or town end county and state) SIC.DESCRIBE HOW INJURY OCCURRED:
MONTH DAY YEAR
1 I 1
I ml I
.'` 31D.PLACE: 1 31E.AT WORK? 32.WAS DECEDENT HOSPITALIZED IN 33A.IF FEMALE,WAS DECEDENT 1 338,DATE OF
1 NO YES LAST 2 MONTHS? NO YES PREGNANT IN LAST. NOI YES I DELIVERY: MONTH DAY YEAR
I 00 01 00 01 8MONTPIS? 00 ❑ i 1 I
Affirmation to be completed by informant:
I affirm under penalties for perjury that the information given in the,facsimile of the cotlifical: of denlll for the deceased
person identified above is true and correct information to be added to the original certificate of death and the local registrar's
record.
( (j4
0` Fitt.Or ne:.,..•w.r,In LVr, :.'.,l
t Ito-t-Leir -----,__,- -- ri Ig(11
To be completed by registrar of vital statistics:
The above information has been added to the local record of death on file in this office.
Lleps1 nr ,Alumnae. `-'l T DOSIIK•I Number f)nlr',
DOI 11999(1/R8) d56411
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Stion Burial - Transit Permit
iiliiii Name First Middle Last Sex
iii of 2-, IBC LE}i ,J rtzl
Date of De ath A e If Veteran of U.S. Armed Forces,
D 41 R72_ War or Dates JQ'-f 2- /q -
Place of Death Hospital, Institution or
2 City, Town or Village Street Address
0l Manner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide 7Undetermined Pending
f Circumstances Investigation
Medical Certifier Name Title
ai
Address
'` Death Certificate Filed District Number Register Number
ssCity, Town or Village ,k'.tls(fi( 56 517
Date Cemetery or Crematory
❑Burial
Address
: ❑Cremation
• Date Place Removed ,
Removal and/or Held
2 ❑and/or Address
Hold
0 Date Point of
NQTransportation Shipment
fl by Common Destination
Carrier
Disinterment Date ��2g.'20 1 1 Im ry?Ad ssi, e rr_ ,.�^^ - ,Q,n I
titi
Date ��C,,e��m_""et�eryvAddress I jaij 3Ck..u.((uiatlle 1.'(
Permit Issued to Registration Number
Name of Funeral Home ' l\(2'gvl 4-teal yu�2h4Q glr - D ItoZZ
Address �l
4 o icy (•eelks lDuvt.c, i.)q t o Srr+
"`' Name of Funeral Firm Making Disposition or to Whom .
'" Remains are Shipped, If Other than Above
110 Address
rg
.ail
tl
': Permission is hereby granted to dispose of the human remains described above as indicated.
i Date Issue . 2 - 2JI J Registrar of Vital Statistics C . ( Ai.
signat re)
ii District Number c Place f C') /r� �jL
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
W Date of Dispositio L?5( L(Place of Disposition l4- 6,4 . C.tr'.q '
2 (address)
Lu
1C (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
CI
z (please print)
Signature Title
(over) '
DOH-1555 (9/98)