Godfrey, Robert M. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Rir)st ` M�idtlle - L st Sex
Date of Death Age If Veteran of U.S. Armed Forices,
War or Dates
-- PlacqotAeath �n1 Hospital, Institution or
City, Town or Village (-�- A n r'\ Street Address /00 JS S Tp7ERTF,
Manner of Death Natural Cause Accident Homicide Suicide ElUndetermined El Pending
Circumstances Investigation
LU Medical Certifier XXX /fin Name Q Title
MOO
Address
A4S
Death Certificate Filed ,�� District Number Register Number
City ow or Village r0 r n 5--7 IS
❑Burial Date Cemetery or Crematory
❑Entombment rn cH �41'1 o
Address
[XCremation TO(.�/ O !"W9'� cO
Date F15ce Removed
Removal and/or Held
and/or Address
�= Hold
Date Point of
Transportation Shipment
d by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to n� Registration Number
Name of Funeral Home (vie rx ��� D(i I -7
Address 1 � � f ox 8 Ce NV 12� - -7
Name of Funera-Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LIJ
�` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued O 3 I 1 2,02-0 Registrar of Vital Statistics (,(
(signature)
District Number y Place F(4 Ann �(�i�Yy/-k
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3` /Z-ZO?oPlace of Disposition f,�� y ,�r✓� � rnc�-�r�/y
(address)
(section) (lot number) (grave number)
jM Name of Sexton P son in Charge of Premises �w����'t �eL4., �4_k-e-
++�► i (please print) LL
Signature Title � cAn'
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 01342U,
Receipt
Human remains of delivered on l
20
"
Pine View'Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ' `,