DeMarsh, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
giii Name First R / Ule 1,, ,Kg ys� Last Sex /vi
t c (,rcr✓a L. �
Date of ath Age If Veteran of U.S. Armed es,
111111111 l ,,`'� q7 War or Dates °�4r2
Place o Deatfi / Hospital, Institution or /�
City, TQ Lr Village- VIVO' 1 er/is Street Address 17 tit,h ci-
Manner of Death[Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name A 1th�� n cf.y 4 cite.G ("jJ
Address 3 q 1 ,O
1.1 Death Certificate Filed / District Number Register Number
City, Town or Village 5 6 00 I L 5'
Date Ce ery or Ctery�fatory
11 Burial golf/ 7
, tL►eV' ' ' C/ 4
Addr Address
❑Cremation
Date Place Removed
2❑Removal and/or Held
•- and/or Address
aHold
0 Date Point of
5 ❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
IP Permit Issued to c/) Registration Number
111111.11.1 Name of Funeral Home 5,,it,/,th / l(lk hale I 0 Cle-- 0r i" 7
Address I
` 07fr3 leyy c V I,cr v-t-ct r S 1j vv r
>`' Name of Funeral Firm Maifing Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fl
Ik
Permission is hereby granted to dispose of the human remains descri end abboveeaa indi d.
111111111 Date Issued / /23/97 Registrar of Vital Statistics �QG fir.! !�
(signature)
11 District Number 5 601 Place � '. � S U ) - 0 I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
tuDate of Disposition J_/29/97 Place of Disposition Pine View Cemetery ,Queenshury .NY
2 (address)
LuCA New Kenesaw 4-A 6
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Rn�nee, c; Mr,,hP,�
g (please print)
lU Signature Q Title Super_;_nyenden}
DOH-1555 (10/89) p. 1 of 2 VS-61