Winslow, Robert E it 4.3
NEVI YORK STATE DEPARTMENT OF HEALTH • - l'NEW
Vital Records Section Burial - Transit Permit
Name ifirsl, Middle Last ' Sex
Date of Death Age ' If Veteran of U.S. Armed Forces,
//— / '7 - r Of 6- , q''� War or Dates IJO
44 Place of Death Hospital. Institution or
City, Town or Village Ale.viceinh ( Street Address' ✓iy f
Manner of Death sp,,I' ' atural Cause Accident Homicide [l Suicide Undetermined Pending
Circumstances Investigation
4.41 Medical Certifieili Name Title
VtV" •\ter - �
Address , '
N t�C b '\ . Cp.A C' -cc" �_ 11/% - , ` _
Death Certificate Filed District Number / • Re ister Number
City. Town or Village /VQa.! CCf1 h /s:6-y Cbt‘ - 10
Date C etery or Crematory
C Burial //— i7 - ar-/ hue v1 eq.) ere,m6 .T.r/
Address
.:. emation v GCvil,s b vfry y '
Removal Date 'lace Removed
and/or Held
L. and/or Address
�' Hold
0
Q Date j Point of
mn Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'!> Permit Issued to f / ! Registration Number
Name of Funeral Home �ijq i-0,.. L. ,rCe.,l// ,veY0 I Mow' - __ 077-577
Address -504-07L i-,A A"-z-- l to 2 P
Name of Funeral Firm Making Disposition or to Whom
w'' Remains are Shipped, If Other than Above
gAddress
lilw
';__ Permission is hereby granted to dispose of the human remains describe bove indicated.
Date Issued /lam IF-aO/r `Registrar of Vital Statistics
(signa re)
iW
District Number / 5 Place "UQuJ Celia- '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
W Date of Disposition gill flY Place of Disposition 4'N0...4 t�.7vri,....,
W (address)
t/a
GCC (section) /l (lot numb3 (grave number)
Name of Sexton or Person in Charge of Premises „ _ Z.-
z 4 (please print)
. Signature ,1 7 Title Am
(over)
DOH-1555 (9/98)