Russell, Carl NEW YORK STATE DEPARTMENT OF HEALTH
I/
Vital Records Section Burial - Transit Perm
Name First Middle g7,..,
L ast Sex
Ciq�/ �t s sue/ /4-7
Date of Death Age If Veteran of U.S. Armed Forces,
Q r- `f- /7 War or Dates ND
Place of Death Hospital, Institution or
City, Town or Village /Ud}- U ISc A) Street Address g y-s8' L)-S leri
0 Manner of Death-(v'(Natural Cause El Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
W. 1' ' Circumstances Investigation
ut Medical Certifier Title
VS 57-Ccireri)Uvy /9 rP
Address ,
/o Q, k1 ��( ' 6 l c---14 6 mi4. LAI-0 (
Death Certificate Filed - 1 District Number Register Number
City, Town or Village IL)O Y.- /V di C L) /-S / N N -a 0 5
❑Burial Date Cery or Crematory -y�
❑Entombment " 'A/e/I1 CO ��ivA�; 7'
Address
igKCremation 0e)Q./61.5 A 0 T
Date Place Removed
3 ❑Removal and/or Held
44 and/or Address
— Hold
40
0 Date 14) oint of
ti❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
iiigEl Renterment Date Cemetery Address
Permit Issued to // ,/ Registration Number
Name of Funeral Home�, ,iAl--ct A. '4!.i op.efrA1 JY � CIO 5-7 Y.
Address �� Ay: /M70
O
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;'; Address
t
9:` Permission is hereby granted to dispose of the human rem ins described ab e as indicated.
Date Issued l 5.0` �)\C\Registrar of Vital Statistics RB--.�-?'--'i, .�,, �2/
1
l (signature
District Number `s-4` Place 04y1 j Y /6/
✓
1>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI• Date of Disposition '1'72in Place of Disposition Tipce", ork,•\
a (address)
Lu
CC (section) (lot number) (grave number)
/ tt
ci Name of Sexton or Person in Charge of Premises I �^�{`T
Z 14 (ple a print)
W
Si 4gnature ( Title / ElMaTUit
(over)
DOH-1555 (02/2004)