Cummings Sr., Robert NEW YORK STATE DEPARTMENT OF HEALTH +' 1. 3
Vital Records Section z Burial - Transit Permit
Name First addle Last Sex
Date of Death Age If Veteran of U.S. Aryrfkd Forces,
/0` ,1 `I 116 7 War or Dates VV
p- Plac- : *eath ,'`�� Hospital, Institution or
W Cit Tom •r Village cat. cA>jK r Street Address 0,..Me..*N_ E kie.-Li -1- kt.t
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W Manner o Death N Natural Cause ❑dent ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ILI Medical Certifier Name Title
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Address 0 ) /� // 1 c�
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Death . .cate Filed District Number �.J Register Number
City wn Village ( 4.c s.S...r S 5 7 l`t!
El Burial Date / Cl Cemete or Crematory
❑Entombment (� /�a/ . 0, ,A. v:,w C.114 :tea+or
Address P
NCremation 0 e,tAy.L.. z,,, 7;
Date ( ) Place Remove
Z Removal and/or Held
0 ❑and/or
E Address
IA
Hold
O Date Point of
5❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
M ElReinterment Date Cemetery Address
Permit Issued to Registration Nu ber
Name of Funeral Home sM v.� 1 fc.x er. ( H.•,..t -7-e_ O- �`t f
Address 7 X e 1 a.A._ AV .',:- ,\i f I?
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
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II` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued k 0-aa-).0 12 Registrar of Vital Statistics 7.44.-4 'k-A..e,CG'L--'
(signature)
IR District Number 5 V S" 1 Place (oU'(1S bvr y
I certifythat the remains of the decedent identified above were•c1{s osed of in accordance with this permit on:
0. p
Z ILI Date of Disposition /oj 13(I 1T Place of Disposition i e\ ,,,,t �"eto.-v
(address)
LLI
0
IX (section) (lot numb ) (grave number)
ci Name of Sexton or Person in Charge of Pre ises
I r.br� Sa44L�'
Z (please print) 1
aii
il Signature Title (401411_
(over)
DOH-1555 (02/2004)