Rosech Jr., Robert # 0 Ii3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
....
. _
Name .._,,Firs Middle Last Sex
-16-e-dc_ al,,wi--)- _.. R-t,-. -,-J-
,
Date of Death 1 Age ; If Vetere of U.S.. Armed Forces,
tc, i War or Dates
Place of Death ---• 4Q2-,,,) T Hospital, Institution or
, Ci , Town or illa ic 1-cato I Street Address
,i. Manner of Death usr771 Natural Cause 0 Accident 0 Homicide E Suicide 0 Undetermined El Pending Circumstances Investigation
0
ILI Medical Certifier I.\ Name , Title *
Address
/ G i C--o...! V•-_ac Q._--(---_, ‘...-AZ_Q.---,--.4:2-A-).-4-1.- NIN-Ika_
Death Certificat ed Th- 1 District Numbei
Register Number
City, Town or i11a9e ,3 6-1-- i
['Burial ! Date 1 Cemetery or Crematory
0 Entombment!
A5idress
N(\-A"-' \ ---, -e 0 -1*-
1 Date r Place Removed
g -1Removal 1 i and/or Held
--'and/or I Address
Hold i
Date i Point of
02 1_11-1 Transportation Shipment
by Common Destination
Carrier
....
ii Disinterment
Date 7 Cemetery Address
•
E.]Reinterment
Date I Cemetery Address
i
Permit Issued to - 1 Registration Number
Name of Funeral Home 11-1 6 KL-Q---- ---- 'i----Lt--,---z-,---(.._ 1 4-6-----(..., 1 c \
Address
•
. ,1
Name of Funeral Firm Making Disposition or to Whom
tz. Remains are Shipped, If Other than Above
2 Address -
Zr.
Ut
.1:3. Permission is hereby granted to dispose of the human remai described a!,.v.as indicated. 1
Date Issued 2.b 7/0 Registrar of Vital Statistics
(stgrature)
• District Number 415,2 Place 5 Luj, 3114,3 ri- --: A get,t1 Ye(g 62803
4...., I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
Wi Date of Disposition 711411 Place of Disposition _.. gov.,) ,e...0._
(add(ess)
ta
4A
!1 Name of Sexton or Person in Charge of P emises fisection, _ , (lat numbri
,)e.,l fg-eve number)
2: , lease pnnt)
la 1
Signature .1.... -f____ Title [POIIITY
(over)
DOH-1555 (02/2004)