May, Rodney W. NEW YORK STATE DEPARTMENT OF HEALTH
vital Records Section '
Name First Burial - Transit Permit
Ro ^� Middle Lit
Date of Death r` L) Sex
1 Id Aye <•�r If Veteran of.U,S, Arme a orces,
Place of Death War or Dates ► S� - S
Cit . Town Villa Cvr.,.� Hospltal, nstltution or
Manner of Dee Street Address 3 i a �.y_ 7�_
[�Natural Cause Accident [�Homicide 0 Suicide Undetermined
Pending
Medical Certifier Name Circumstances Invest i anon
A�- C Title
Address
Death � flc �, (.via
cafe Filed
Di tct umber Ca-y;`TS�rVilla e 'J� 4S� Register Number ;
Date f
Buriall�,�,Z � �� � Cemetery or Crematory
Address
Cremation
lO Q Removal Date Place Removed
and/or and/or Held
N
Hold ddre
Ass
Date
[�Transportation Point
Shi mant
OY Common Destination
--
Carrier
[]Disinterment Date
Cemetery Address
Reinter ment Date Cemetery Address i
i
i Permil Issued to ~�
Name of Funeral Home J f� Registration Number
Address..Name of Funeral Firm Making �d�
Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LL
Permission Is hereby granted to dispose of the human r a ns scribed ov
icated.
Date Issued I a /y � � Re�istrar of Vital Statistics
a re)
District Number Lr j 5 Place00
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f—
w 101
Date of Disposition I Z h Place of Disposition_ (�
ivUw �rtJ�f(yti
w (address)
(section) lot number
0 Name of Sexton or Person in Charge of Premises !
(grave number)
lrwlt�
w Signature (pleas Tple t) i
�� RA
-Oh 1555 (10/89) p. 1 of 2 VS-S
Public Health Law Sec. 4145(2b) 013182
Receipt
Human remains of f , delivered on
��; �ice,, --_ _-l::'✓�" - :� �.-._.....---_
Pine View Cemetery presenting the funeral home named on burial permit
6fficial Funeral Directors Reg.or License#