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Rosebrook, RodneyNEW YORK STATE DEPARTMENT OF HEALTH Wof Vital Records Section Burial - Transit Permit Name First � Mjddl Last. Sex Irco Date of Death Age lU Z ZD) If Veteran of U.S, Armed Forces, C15 War or Dates Place of Death 6+tt, Town oF+llage �� Hospital, Institution or Street Address I C21/lr Manner of Death ©'Natural Cause Accident Homicide 0 Suicide ndetermined Pending I<EE Medical Certifier Name ` �+ Circumstances Investigation Title I I I IQ Address -7 3i2 v 9001 Death Certificate Filed District Number n Register Number City, Town or Village 5 l []Burial ❑Entombment Date 1 Z3 JZo►q Cemetery or Crematory fi 'i ne `� e CV e Address [cremation Z Removal Date Place Removed and/or Held and/or Hold Address Date Point Q Transportation of Shipment by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Name �r II II� Registration Number of Funeral Home ► �1C� d 0-7 Address qj SOA CW5 3 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address I Permission Is herreb granted to dispose of the human rem s described above as indicated. Date Issued d 0`Ct Registrar of Vital Statistics District Number C^Place (signature) ct I certify that the remains of the decedent identified a ove were di posed of in accordance with this permit on; I� Date of Disposition /a Place of Disposition (a ress) (section) (lot number) (grave number) fi'V- Name of Sexton or Person i Charge of remises z (pl se print) Signature Title r!ilrrAdw (over) DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) 913019 Receipt Human remains of delivered on, 20 Pine View Cemetery Representing the funeral 6me named on burial permit Official Funeral Directors Reg. or License #