Nelson, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
pi Name F -!idle Last Sex
iil:ii: It oC)e�-T— 11 Ndre Aid Sa NI M
Date of Death Age If Veteran of U.S.Armed Forces,
5.')-`/ I go War or Dates
Place • 'eath Hospital, Institution or, n r
C , . Village .+ e e Ws rJ U l Street Address Z3S C esTAJw I R+ t4,,e Rog a
I Man _, ' Death Natural Cause El Accident Q Homicide•Q Suicide ❑Undetermined 0 Pending
Circumstances Investigation
fel Medical Certifier Name Title
g NM ON Pe (_ 14 CC i1 /1- 1 '' _
Address
`3 J Yo+v G41 It Ct N're --- ( re/Jr&re/Jr no I fsf tl&-c,Yoi-K /2 o 1
1-1 De-1 _.rtificate Filed District Number Register Number
City,VI or Viilage 49 u e e rJ S 6 u C) (Q
lABuri. ��
0Entombment ° ley Cemetery 7- t/ SeetyeS Celle 1c_�-
Address
nCremation COL(e en)S b t(1-�{
�We_w y r- ,
C
Date Place Removed
❑Removal and/or Held
t H old
of Address
13.,,, Date Point of
a D Transportation Shipment
by Common Destination
Carrier
Bii El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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Permit Issued to Registration Number
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Name of Funeral Home G,i nQ rc . 6(11.er Ftinert i irkbsrn- 0-1-4 yq
Address �a yQ.fie- SA-, , Q u eesmsbuiv , N e yur L. 12 O LA
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
Permission is hereby granted to dispose of the human remains described above as indicated.
".,.::{_` Date Issued ) L.t Registrar of Vital.Statist'
-KG._ Q, 6.3Ja2
(signatu1e)
iiiDistrict Numbers ,s' Place l � C)---- 1_1 s7
:::':=: I certify that the remains of the decedent identified above were disposed of in accor this permit on:
Date of Disposition 5 '7 1 I Place of Disposition ' ,S - L' esi .
114
(sedion) (ktnumber) (grave number)
Name of Sexton or Person in Charge of Premises li.-'4-10 Lk3 u�,_.,
, -- oease pal
gi
e. Signature °�- Title p c,u-:t/ [V-/--`-•-
ml
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(over)
DOH-1555 (02/2004)