Melville, Russell • i V
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial ansit Permit
Name First e..- Middle Last Sex
k_„, l l S •
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Date of Death Age ' If Veteran of U.S. Armed Forces,
•-I/ ,f'/ a„oi7 q War or Dates /.--...) 0 et-ta-_�
Place of Death -- - --~-Hospital, Institution or
City. Town iilag - Street Address )r Dal
LLA
W Manner of D Natural Cause —Accident Homicide 0 Suicide Undetermined —Pending
—Circumstances —Investigation
Medical Certifier Na i Title
CI JI � -�a-‘4-e^ �, M,
Address
J �-- / Ari( c 6-L ¢ -. , pi 7 1 01
Death - .cate Filed District Number �S Register Number
City Village �� r:
Date Cemetery or Crematory
Burial 1/ 17 /a017 n - l/ L'Mr---------
Address
QCremation -6e„(--7lJ ,1 ) f1 `l'
Date Place Removed
0• — Removal , and/or Held
I— and/or Address
• Hold
O Date Point of
CI 0 Transportation Shipment
Gs by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
J
Permit Issued to �- Registration Number
Name of Funeral Home _�/sm.)r< <A -A_e r. C -"- r .J,- _ oc,,i-r i3
Address
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Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
41
Permission is h reby granted to dispose of the human r:- • :scribed ov- -s' •icated.
Date Issued I ! a0/7 Registrar of Vital Statistics AU.► - 4
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' District Number 1-1'2 � Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Y/77/7 Place of Disposition j ,?>1P_J R!- m
2 (address)
uj
CC (section) ` (lot n mber) (grave number)
.Name of Sexton or P son in Charge of Premises --J Tex_li c<-,''j e
Z i ' (please print)
u1 Signature Title G42. /7-70, ' .e/?,
DOH-1555 (10/89) p..1 of 2 VS-6-1