Green, Richard L. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir t Middle st S x
CY14 Kj L, Q>
r'�
Date of Death Age. If Veteran of.U.S.Armed Forces,
,.�: r,+ •�: sue/!(/ ',V1lar.or bate8...
Place of Death Jo Hospital, Institution or p
City,. ow r Villa e�v Street Address
Manne-r-ol Death Natural Cause Q Accident ., Homicide 0 Suicide ❑Undetermined ❑Pending
:a Ci
rcumstances Investigation
Medical Certifier Nam Titl
ddres
r,
Death - ate_Filed District Number Register N tuber
C1 nor Ila e
..Dates
C J C tery or Crematory
❑Burial Z- _
Cremation -77
A -
Date Place Removed
O F-1 Removal and/or Held
and/or Address
Hold
0 Date Point of
NQ Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to �— Registration Number.
Name of Funeral Home �T�A �v"arc c-y
.Address
Name of Funeral Firm Mak1hg Disposition or to Whom
Y Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose.of the human re s scribe ov s in Gated.
Date Issued 2,-Oq-2dW Registrar of Vital Statistics
si n ture)
District Number 1-t_ r 3 Place
1 certify.that the remains of the decedent identified above w`r disposed of in accordance with this permit on:
ZL Date of Disposition 1IS IZb Place of Disposition �u�.. 4tVr�
(address)
Uj
(section) lot number) (grave number)
Name of Sexton or Person in Charge of Pr es rJ Aul
g (please print)
Signature Title �Rb+►►�'i0t�_
DOH-1555 (10/89) p. 1 of 2 ci i�_LtI? Ca `riVS' -61
Public Health Law Sec. 4145(2b) 14 .. 1-3 3 J
Receipt
Human remains of i delivered on ` , 20
Pine View Cemetery lwesenting the funeral home named on burial permit
Official Funeral Directors Reg.or License#