Rockett, Charles NEW YORK STATE DE ARTMENT OF HEALTH
Vital Records Section , , Burial - Transit Permit
> Name First 5 Middle`, `a\ Last ec Sex,- ^
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Date of Death A4
2 If Veteran of U.S. Armed Forces,
)Z1 ) I )s 'l5 i War or Dates 1c1 5q - 19 1p 1
)4 Place of Death I Hospital, Institution or 1
Zit own or Village Glens F�1�5 1 Street Address G-nS �a11S -Hos pi+q I
Manner of Death 2 Natural Cause 0 Accident El Homicide El Suicide FlUndetermined �Pending
Circumstances Investigation
4 Medical Certifier Name Title M
wa r-1-- SonzC)
<>_<:.3 Address
102- 141)1it-- S • G-IQns Pc ►ls, Ai i 2-5 0 i
Death Certificate Filed i District Number Register Number
iiii'ilailo Town or Village bl.ONS --al 5 60 I S Q 9
Date m,etery or'Cremato 1
❑ Z Burial \ l �� �S r c J 1 ev3 Crevna raj
Address
2 Cremation N I Z f Q 4'
Date I ; dace Removed
. :(.1
ri Removal and/or Held
2 and/or Address
- Hold
U)
Q Date Point of
NQ Transportation. I Shipment
a by Common Destination
Carrier
Disinterment Date ' Cemetery Address
:ii ElReinterment Date j Cemetery Address
i Permit Issued to _ _ Registration Number
Name of Funeral Home 3i-}t612_ i-SA-,&11,;-L_ A Al 0l/SQ
Address
I/ 1, b> I L' i. (9uF.2r,os tS U rLd
- / I
aName of Funeral Fim Making Disposition or to Whom 1r
E. Remains are Shipped, If Other than Above
4 Address '
lij
4
Permission is hereby granted to dispose of the human remains described above as indicated.
m.
Date Issued 12 /ri 115 Registrar of Vital Statistics lNc N-Q
iia
(signature)
District Number 5 60 I Place 6 CAS 1 `\S P' /Zf a/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
14
5 Date of Disposition J1--/7-ic Place of Disposition ) .ii 2 U re 14..) L re/Nc,-10-7
(address)
www
VJ -
C (section) (1 number) (grave number)
GName of Sexton or Pl.erso in Charge of Premises N./LA/raft o.-n l c,c..l.e
Z (please print)
t4 Signature Title C l� i/a..-/'o1
- (over)
DOH-1555 (9/98)