Russell, Marion NEW YORK STATE DEPARTMENT OF HEALTH .:. # I 0
Vital Records Section Burial - Transit Permit
>< Name First)j Middle A..ast Sex
/ I Ort i o,u %i.�t rhi- X i}SS 61,C_ Fe 116 _1(
Date of Death Age If Veteran of U.S. Armed Force ,
)2 (3 (11 IZ War or Dates ^f/✓d
Place of Death Hospital, Institution or
r, ' City(fown r Village p L-TD.,,! Feet Addr `9// 7 ju�'lax.i i J.
Manner of DeathaNatural Cause ID Accident u Homicide 0 Suicide 0Undetermined ri Pending
Circumstances Investigation_
Medical Certifier Name Title
t 218) J J i 0 /t-th
''a Address
giiiii Death C ificate Filed District Number ' Register Number
City owr Village T v L ,
'<''OBurial Date Cemetery or eemato l
" OEntombment i /3 it [S 1` /4
Address �
` ernation Q v i97L E�.� l�- 3 V a ,-'S�3
... Date Place Removed
O Removal and/or Held
.. : and/or Address
,r Hold
Date Point of
IZ 0 Transportation Shipment
"" by Common • Destination
Carrier
<',Q Disinterment Date Cemetery Address
< ;O Reinterment Date Cemetery Address
iiiiii'< Permit Issued to Registration Number
> s Name of Funeral Home .fit„_ 1c,.A.)CzNn..,A-L__.Atit,/ 01130
`.ii ' Address
it t 0-1Fday V gri- .-IS 3 k-A1-7 Aly
Name of Funeral FitM`aking Disposition or to Whom
```. : Remains are Shipped, If Other than Above
6-=: Address
'a,> Permission is hereby granted to dispose of the human remains d scribed above as indicated.
Date Issued1 O3 l20 �( Registrar of Vital Statistics i
l (sign ure) •
District Number 5Co50 Place rb. -f -t t ay
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1/ 8 lit Place of Disposition , ' ./ to
(address)
Ui
(section) A (lot number (grave number)
ft
Name of Sexton or Person in Charge of Premi s
r.. ..V
please pnnt)
Signature 6 Title 11ZOitrfil
(over)
DOH-1555 (02/2004)
k