Robinson, David NEW YORK STATE DEPARTMENT OF HEALTH Burial m Transit Permit
Vital Records Section
Name First Middle Last Sex
s tom. QN i d Mococ r �l tobinsor� Mc� e
G _ Date of Death Age 1 If Veteran of U.S.Armed Forces,
< F:ebrt kcuy L. 120 l i -13 I War or Dates X
l PI ce of Death os , institution or
ill� i r Town or Village ef1S �� S Street Address 6 lens Eo \\s Hos
® anner of DeatlNatural Cause 0 Accident D Homicide 0 Suicide El Undetermined El Pending
III L' iCircumstances Investigation
0
to Medical Certifier Name Title
6-P% IC. P, u.6-n AJ
Address r //
L tS..r3 / 6�-{.,5 '7tS P a 15.t 7 F7iJ
>': Death Certificate Filed District Numb r Registerf N er
it Town or Village IDS Fa_f Ir
Li Burial I Date Cemetery Crem tory \,
['Entombment Address int VIP Cre/vtac��O f'7
Wremation ULtod 1 Zed , Que.eru-bur , /�/e-.J York- /zia y
1 Date Place Removed
3 U Removal I i and/or Held
and/or 1 Address
c
Hold l
-0 Date Point of
coTransportation Shipment
a by Common Destination
Carrier i
«> Q Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home .\/--N-,1L;z � HO l C 1\ L
Address r. r e'
Name of Funeral Firm Making Disposition or to Whom
li Remains are Shipped, If Other than Above
Address
C
1LI
CL
Permission is hereby granted to dispose of the human remains d cribe ab ve as' dicated.
Date Issued 0.2:- 2//2ez? Registrar of Vital Statistics
(signature)
District Number �j�/ Place ‘4,‘.
/Z', Al)/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lei Date of Disposition 24410 Place of Disposition Qnt Ui t .j e�Mi h•,wtph',v.,,
2 (address)
U,
E (section) /'/ (lot number) (grave number)
0. Name of Sexton or Person in Charge of Premises /�r,;i'J)1J,- �t+tlf
2 (please print)
Signature Title f� AP�
(over)
DOH-1 555 (02/2004)