Rosebrook Sr, John �
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NEW YORK STATE DEPARTMENT OFHEALTH ,
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��~~° .~~x u . ~~.°~~nu Permit
Name F MVe8ex
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D Age ^� / If Veteran ofUS A
6r ^« War or Dates
P|mo Hospital, |nndtudu"6< '
4.1 City, Street Address .
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u/ncumstanoeo Investigation
Medical CTitle
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Death Certificate Certifionte Filed - District Number7 ' Register Number
City, Towp or V46-ige
Date Ce Crematory
Buria|
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Cremation
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Rem a' ^~^~^~~
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uou/u/ Held
and/or Address
Hold
Date Point of
F-|Tnanupodation Shipment
by Common Destination
Cnnior
Date Address
| |���bsnnen� °= "�"=x
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iRe(n�onnen� Date CemeteryAddress
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Permb |ouuodtn r?- Reom�edonNu[pbe/
Name of Funeral Home �� �� . -��v' - �� 0 0 -�
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Name of Funeral Firm K8akinQu/apusdionortnWhom y7
Remains are Shipped, )f Other than Above
Address
Permission is hereby granted to dispose of the hummmn remains described above as)
Date Issued ,20. ' ^vF(egiotrarof Vital Statistics �.
(/ (signature)
�P|000 District Number ^�»� �
_-__- -'- y
/ cerdfv that the remains u/the decedent idend�odabove were d�pooedof inocoondan �!U` thiu /7i!^on:
Date ofDisposition 6/22/94 p|onenfOkapoohinn Pine \7ievv Cemetery Qoeenobory NY l 280-4
(address)
LU
Hudson #3 13 7
(section) (lot number) (grave number)
Name of Se n or erson in Charge of Premises Rodney G. Mosher
in
(please print)
�W Signature lea Title Gupt .
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OOH'1555 (10/88) p. 1 of VG'Si