Russell, Roger NEW YORK STATE DEPARTMENT OF HEALTH - x A Sob Vital Records Section Burial - Transit Permit
.
Name First ,v_ocMiddle Last Sex
Y---17 one_ �`1SSP�(
Date of Death Age If Veteran of U.S.Armed Forces,
'" 1 i J J 4 g �U War or Dates
P - of Death Hospital,Institution or _ -
V or Village G1 (cn A FGc_t�ir, Street Address J Cam-i' S-+- . A-'-j --La
grown
` - of DeatnRilatural Cause Accident El Homicide 0 Suicide u undetermined U Pending
}rCircumstances Investigation
_ Medical Certifier Name (�OJ u s}'1CA�'1 Scx�n cep l c�n Title ri 9
Address li l�( Ca-le • 0 -1- b,-'Y- ) 1 Niq ) Z c�
;',- .- ' Certificate Frted , District Number Register Number 30D
n or Vilage ,Q Fi 5001
Date Cemetery�)
• I I ( e GJ
■ Ce j2� ( Zol � V
Address
Cremation 0 c Ct- ' Y O r,G G-ue_to r1 Sb v r t``'-/ /Z kU L)
Date Place Removed
0 Removal and/or Held
a
•• and/or Address
-, Hold
6. Date Woint of
`:+0 Transportation I Shipment
qi by Common Destination
Carrier -
[l Disinterment Date Cemetery Address
Reiriterment Date Cemetery Address
,; Registration Number
Name Issued to t Maynard b. er er ' HDme_ QI 130
Name of Funeral-�Ho(/me�`r
' Address ,i LC.CTt e at. ,b tit.Q ernb -rd t lie-LA) qvrk- /2 80/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
} Address
13
t Permission is hereby granted to dispose of the human remains described above as indicated.
?�r' Date Issued 6 /.2 0% I$Regisstrar of Vital Statistics UN)CAA 4 c. �.A.At /�/
(signature)
,r° District Number 5 6 o J Place G (SZ/V-C•Ve it S J 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4/zS 11 t Place of Disposition r d•-✓ /i/ t..
(address)
y (section) (lot number) (grave number)
a; Name of Sexton or Person in Charge of Premises 14
1
All
ease
Signature d (please
� Title 1 IIII
• (over)
DOH-1555 (9/98)