Barber Jr., Roy NEW YORK STATE DEPARTMENT OF HEALTH # 113
Vital Records Section Burial - Transit Permit
Name st Middle Last Sex
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\1 1— I ,r-be r JY Malt-
-::. Date of Dea h Age If Veteran of U.S. Armed Forces,
a— 9 — 18 9 Z War or Dates t.I o
I-- Place of Death Hospital, Institution or `IQ
Z City, ow or Village I—Q.CI I / Street Address (D�J5 R T�— q a
pManner of Death Natural Cause El Accident I]Homicide El Suicide EjUndetermined ED Pending
IL/ Circumstances Investigation
ill Medical Certifier Name Title
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Address �I
Cof-in �r1 N\f
Death Certificate Filed, Districtrer Register Number
City, Town or Village 4ad l e 5 O I
❑Burial Date _ Ce etery ors Crematory
❑Entombment a - oZ O l$ F) n e.V i e-t.C) -f'�rn 9
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remation USl.{,CCv 5bfr 12 0''
Date ace Remo ed
Z Removal and/or Held
2 and/or
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tri Hold
0 Date Point of
a., ❑Transportation , Shipment
ES by Common Destination
Carrier
Disinterment Date I Cemetery Address
: Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homebr A,O-QX k,uv-lZ rail l ,yve_ )n G (9 0 .D-( L
Address 0,4 ChL X-Ch 5 t Lai<.e_ La ie9r-nc, Ivy I L S 4-00
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
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Date Issued ,Q I 1 d ) 8 Registrar of Vital Statistics u�, (,`- , 4�`
(signature)
NiDistrict Number s5-x Place T ton D -- )4ad Ie
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Lt Date of Disposition a/1Y f,n t N Place of Disposition Pi h.,t, "V i eA) Gfcn,40fy
2 (address)
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CC (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Tam—L.y StJ..t pcs
Z (please print)
14 Signature,// ___. Title &kr+Y+o r
(over)
DOH-1555 (02/2004)