Whinney, Richard //77
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First "� Middle - Last ,,.1.►n 1 Sex H
'A‘c�t1C.�-rd
'-``' Date of Death \ Age q I If Veteran of U.S.Armed Forces,
li 2,2� 12 S 1 ( War or Dates
of Death i spita)lnstitution or
- Ci own or Village el \eA �1d I S 1 Street Address 6 lens Fail &
`E Manner of Deatht Natural Cause 0 Accident n Homicide Suicide n Undetermined fl Pending
fi
Circumstances Investigation
la Medical Certifier Name Title Physic 1
D r. Na.wci 1. &dot_:icu. A enc1
Address
Ib° Par IL St. , Glens to us) 124o 1
th Certificate Filed i District Number / Register N ber
City, own or Village �-i lens Cl S M
Li Burial Date ZI Z%I at)1 LP Cemetery c C ema o � \/ ie J
Entombment 1
Address
::_:;Cremation Q L&o..lcer k .:) 0 Luzzi•-o bu , I 12%0 y
Date Place Removed
k '—" Removal and/or Held
—and/or Address
Hold I
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
_Disinterment 1I Date Cemetery Address
< Reinterment Date1 Cemetery Address
Permit Issued to< i Registration Number
- Name of Funeral Home t7. \C_ Tom;\L,- \ 1--ND j.-1l
Address _
t' Lc:, �i - - S-1:4- : irr;, ' 1 ) I . 12 a C
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
• Address
1M
111
• Permission is hereby granted to dispose of the human remains described above as indicated
Date Issued 21 z --2c 0 Registrar of Vital Statistics W 0ti Q L -A- -
i (signature)
District Number £6 0 i Place 6 �s .1,i s Ai Y
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition 3/2 ill Place of Disposition q`I,k4 li(^'* orrvi,
Z. (address)
Ili
In
i (section) (lot number) (grave number)
a. Name of Sexton or Person in Charge of Premises Ar, r Sd l.."if14 / (pi a print)
Signature Ii dr Title l �['Df'1_
(over)
DOH-1555 (02/2004)