Willett, Robert NEW YORK STATE DEPARTMENT OF HEALTH
775
Vital Records Section Burial - Transit Permit
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Name First Mi e t SPX
Date of Death Age If Veteran of U.S. Armed Forces,
a / `,/ Si War or Dates
P f Death Hospital, Institution or �.,
Pity, T wn or Village 6�s � Street Address �- 1' �s
er of Death®Natural Cause Accident Homicide Suicide Undetermined d Pending
la Circumstances Investigation
at Medical Certifier Name AII.e.A.‘e.ra....
Title
Ad es c 's� Pr iiAt !'� �.a 4 Pain +" C� £L �1
Death Certificate Filed District Numbef Register Number
iiiiliiil City, Town or Village E 6Q I 'l-3
kiiii❑Burial Date / Cemetery or Crematory
Entombment l O f/ 7 / "�J l( 1 h z V-C--,, ��_"'
Address/`,
Cremation INCH.e--e 1.5 !� /J c c� ''t
Date ' 1 Place Removed
Z Removal and/or Held
0❑and/or
Address
tills
Hold
Date Point of
Q Transportation Shipment
0 by Common Destination .
ni Carrier
El Disinterment Date Cemetery Address:iii
'' Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ke.,,vs,„,,, r� ��A_r-t 14,4V ®0`t"r-K7.iin Address /0)- gr. L),1.). -
c/ f. t
Name of Funeral Firm Making Disposition or to Whom 1 )
Remains are Shipped, If Other than Above
2. Address
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tiu-
Permission is hereby granted to dispose of the human remains described above as indicated.
IN Date Issued 10/ (/).- i t Registrar of Vital Statistics (Jp .-ki-.k �(sign ture)
District Number 56c)1 Place 5(( r 1)S, A)y
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
III Date of Disposition Cp--'�--?�,t1 Place of Disposition Zte_v:,j.,J Cr-e,ni kd i'uvet
(address)
111
01
l (sectio (lot umber) (grave number)
0
Name of Sexton or P son i Charge of, remises 1 ittnei'L tillruciellt
2 ` ------:: (please print)
W. Signature v.L. Title Cre✓ricAol"y AS4 •
(over)
DOH-1555 (02/2004) •