Wocell, Robert NEW YORK STATE DEPARTMENT OF HEALTH J
Vital Records Section t: - r,i Burial - Transit Permit
Name First Middle Last Sex
fr\O\)E{;- Ed\)3c� ti\Ja� o -
Date of Death Age If Veteran of U.S. Armed Forces,
ry Qti Z`1 ZC1'4) $ ) War or Dates (952 - 1 q7g
Place of Death Hospital, Institution or
P4`=� - al`- S \ Street Address &
� '�;_•;, ter all -00s• ,+a
anner of Death �:1. Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pe ding
Os Circumstances Investigation
ke Medical Certifier Name Title
Dav k d -e. N A
Address
i-ioosnn Pn11s, N
I.--th Certificate Filed District Number Registe Nu ber
ktil Ci > It;'l,i,:* - (1e1- s Fa) S-- 5-61-(
Date 1 Cemetery or Crematory
❑curial oil
J Z 1 Z-O to t; n e V, ev,) Cr emal-r,r
1 c
((D�
Address
lEl.Cremation DI)ePYI Sbj`ry rJ )?8(� 1
Date / / Place Removed
-' Removal
� ❑ and/or Held
.. and/or Address
Hold
d Date I Point of
.``❑Transportation j Shipment
ai by Common Destination
Carrier
0 Disinterment Date Cemetery Address
::::: ❑Reinterment Date Cemetery Address
piPermit Issued to Registration Number
Name of Funeral Home HC nard b. 'Baker Funera/ home_ of 1 3O
Address /J LaFa i e fit• / (Ikeznsbundi Neci VUrk. Jae0'-/
q Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
;i
'µ' Permission is h reb granted to dispose of the human r ains described above as incl. ted
VA Date Issued _ Registrar of Vital Statistics L� )-'72 obi`-e
kw
(sign re)
District Number .57.pQ J Place
?: I certify that the remains of the decedent identified above were disposed of in accordance ' this permit on:
Date of Disposition eliyi l/i. Place of Disposition T(u U?,./ C4 _,,--
(address)
I
"' (section) d'ilipot num ) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
::::. a 4.-
Signature Title a" e
(over)
DOH-1555 (9/98)