Darrah, Richard 7
NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section - , Burial - Transit Permit
Name Fp t r,Middle Last Sec
Date of peath Age If Veteran of U.S. Armed Forces,
Li I Li I I-I- War or Dates .3 - 7
IN Place of Death c Hospital, Institution or
W City, Town or Village ,`Yi\CC.NOC.:.,t� Street Address -K\? '�,iU`E�¢\ hi31WIt A r—
f Manner of Death'' (Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
1LI "" Circumstances Investigation
tu Medical Certifier Name 7.. Title
Address cq 1) (,_-\(\ i.�� S'1- , `�/1�o(,ia t— \
De Certificate File District Number Registe Number
it own or Village �,L1ii �? , 1
Date , Cemetery or Cremator
urial z_� C� b, - l I _
❑Entombment 1i v 'G\J At t w�tar a t� j
Address
: remotion ( •--) +Li. �r\ v;::-ti-r->.5 aL 't`z f
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
H Hold
CA
0 Date Point of
es Transportation Shipment
i3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to — Registration Number
Name of Funeral Home -Svvic)►'-L r`-)'�'t-`zAL. lAC)%A 1E�_ !`At-1-
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CL
Permission is h reb granted to dispose of the human rema ns des r di ablle a ' icatefk.
Date Issued '-� 5/ I1 Registrar of Vital Statistics
(signature)
District Number C1 Place q�,,�„, ^ Sn...
t,u�
I ("�'L t l�(Ql
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a
L� Date of Disposition I un Place of Disposition iu 4- �W+m�`1�Pt+�...
2 (address)
IIL
CC (section) ( per
(lot number) (grave number)
ci Name of Sexton or Person in Charge of Pemises _Stm i'i
ft-
Z (p/ ase print)
Signature G L l Title c 1'�ft1
(over)
DOH-1555 (02/2004)