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Rocque, Clifford 7Gg NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name fiypt iddle Last Sex Date of Death} Age- Ag I e If Veteran of U.S. Aimed Forces, . -- I v g (9-r I CJ Q (i War or Dates )/ / f S�- I'FS w- Place of Death Hospital, Institution o / W City, Town or Village S i-oo IJ Street Address °l`'S 4 i-�Q-� 1W%/! /Z a Manner of Death Ai, 'atural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending W Circumstances Investigation W Medical Certifier ame Ti le o `K06cre-r' it3 eo v Address a z 31 J3or-A,it- P o t_ `bra. A'. ' t a t go Death Certificate Filed District Nurber / Register N tuber City, Town or Village E�.f ©�3 !�j o 3 Date c5o bats- Cem ry or Crematory ❑Burial (! / �� Y %g L Orel() (i^2477 A ❑Entombment Address ptremation �0.Q._eu 5 (AY/ /U. Date Place Removed Z. ❑Removal and/or Held 2 and/or Address •••• Hold CA 0 Date Point of pi ❑Transportation _ Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address ni, Permit Issued to 0 (' - ll / Registration Number Name of Funera ome (�LUAha- 4 . � ly FAt¢ -Al lef troie- O 0-/ 7 AddressC-44-C)1511 A.AZ,-L-- 0Q-y- iX8'70 / Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address CC LE[ P'` Permission is hereby granted to dispose of the human r ins described above as indicated. Date Issued 0 7/ c/ fegistrar of Vital Statistics 't,-/j�,L Cam.1/wi-_0 (signature) Mil ' ' District Number /5703 Place 4;61-0 A g tt _ 4V ,,..,:i;,;i,i,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z ill Date of Disposition 'Its li g Place of Disposition {?,,,V„,. 44 Wr,,i,. 2 (address) LEi U, CC (section) Blot number) (grave number) Name of Sexton or Person in Charge of Premises G hf7tiJ44r 31AAIt1 ff� (please print) Signature •'l� A",r Title ( 1L (over) DOH-1555 (02/2004)