Dickinson, Robert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
2 �' T C ►`1
Date of Death Age If Veteran of U.S. Armed Forces,111 z11 &)N3 COCOO War or DatesI j T
` • Place of Death Hospital, Institution or
City, T or Village \O�i✓Pit'J Street Address 21-7 W h F Te 81 QC i-1 c5-rnTr
Manner of Death 14Natural Cause 0 Accident 0 Homicide El Suicide Fl Undetermined n Pending
Circumstances Investigation
. Medical Certifier Name Title
,.. Cc , �Rul� Fi L ot� +� r17�N CD PH�fSr c i nl
Address
.� \ ccc��a, & C\��- Pc S) �� cZ`�o1
Death rtificate Filed District Number Register Number
Ci Town Village 1\0 ce Cal, . ____ 11,�(o Z ,
Date Demeter Crematory
54Burial 11 12:1 1 ZO13 elNt U \c u- ConaTEiz,v
Address
. Cremation
0 E4NS$\)(Z4 0
Date I Place Removed
0❑Removal and/or Held
E and/or Address ---
55 Hold
Date —{ point of
Transportation I Shipment
by Common Destination
Carver
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
' ' Permit Issued to t ^ Registration Number
.• Name of Funeral Home HCtyric,rd b, cker Fu.nerai f/ome 0(1 30
Address // Lafa -R, 1e at , (�buznS t-rU r/Ul✓GJ Lkr). /a'Oy
Name of Funeral Firm Making Disposition or to Whom �!
- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued r +�a O ) 13 Registrar of Vrltal Statistics ,U m r dAT L
(s ature) /
District Number J�Z Place &J 1 1:�/No L l)$ ID, �/"l 02 AU 102g o? 8
I certify that the remains of the decedent identified abav were d pos in.accordance ' this permit on:
Z Date of Disposition /l�Z77!3 Place of Disposition !re i e0 %14.43 iE 7 ! �,�,15,�3(,��'
(addr )
>A ,F'iCO�✓ 'z
tion) (lot number) (grave number)
Name of on or Person in Charge of Premisescc CiO,c�i6 L- �tiE:�jet
• L^ /' (please prim
Signs e ,Q2 of Title, c �� .
(over)
DOH-1555 (9/98)