Armstrong, Robert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last - Se„....?
i:'.:V.... .7 r .........
Date of Deaf it--(114 A e If Veteran of O. . Armed Forces,
._3- ":7.75 , ..,...1 .......6..... ::,, War or Dates f le/ /7
4' .•-- • ••••••- •- ••
Place of Death
M. Hospital, Institu i r
ii) City,Town or Village ,, 44„rn„,4.16 i Street Addres - )--feaz _ 71, 1/
........... . .....
Mcal Certifier
12 Caus Death ,---,
NameiN
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a... Addre s • ............
]]n u. ath Get icate Filed... ' ' Nu '
.-- r ................ ''''''. "Register Number ......... ....
City,Town or Village
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ate em tery or Crem ory ....,
0 Burial :i. 3-- I.,, , ,,f-7 - -
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emation :iA ess ••-------••••••..------
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Date -- .' PI- emoved
Ci: El Removal / ::.: r Held
),. and/or Hold i...Addieii..... • .........- • - ...
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ta:. bate -------... --...........Point of
----.........— ••••• ••--...-....-
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0 El Transportation by.ii
Shipment
Destination
Date Cemetery Address
,•:.;;: El Disinterment
•• Date Cemetery Address
Reinterment
. •
Permit Issued to ' Registration Number
Aii Name of Funeral Firm . ...... .aa,,.;... ...,:, .........
..................... .. ...................
::.m.:! Address :./. ---- • • •• .- /
Remains are Shipped, If Other than Above
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1.g.i ame of Un .. Irrirm Milking is Rio.. or to .....o ..
Address
At
•••••••••••••-• .... .... • ••••••••• ••••••••• ••••••• ----.... ....
Permission is hereby granted to dispose of the dead h n re ains described above as indicated.
...-/
Date Issued c3-/,‘ ..-,7 Registrar of Vital Statistics
signature)
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District Number _5-40 7 Place 4;2 s ji-
1;7-f--4'.-/
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I certify that the remains of the decedent identified above were disposed accordance with this permit on:
I4:
Z: Date of Disposition '.›.-2 (171r? Place of Disposition i' / vi 6: ( e"4,1 7).- t" 0 "" i () '-i-‘-
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(address)
LU
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cC: (section) -- i ........-- (lot number) (grave number)
cy
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Name of Secton_or Person in Charge of Premises -_-:_/ c..) /.1
C , c....., ' (please print)
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• Signature 6.--1.4. / r Title '--/ .
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DOH-1555 (9/86)p 1 of 2(formerly VS-61)