Streeton Sr., Richard 1 # UI -NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Natoge First Middle Last Sex
IC-ha rd L— SSre e+0r, SR Ma Je.
Date of Death Age If Veteran of U.S. Armed Forces,
Nii (p - .5 I (p 75 War or Dates LJ 0
}- Place of Death Hospital, Institution�Lorr i 1
City,(Towntor Village ►1al i Gi.i1 � Street Address i l h ,JcrrZ at V?Lt ae i 4
0 Manner of Death w Natural Cause ❑Accident ❑Homicide El Suicide El❑ ndetermined ❑Pending
W. Circumstances Investigation
id Medical Certifier Name Title
Dur i (C) T i.Jr ii11 f0 r-)C.r''
Address
380 eb Z,e Inlei AN /33t O
Death Certificate Filed District Number Register Number
City,(iw r Village ),-vi i a<7 La 05'3 --
❑Burial Date I j meter or Cre atory J
['Entombment ,7— I — Go l"1 T k " `e14) ( 'y ma—I
vr:
Address
fa,Cremation lU #cbUXjj ' _/
Date / Place Removed
iS❑Removal and/or Held
and/or
lo Address
8
Hold
Date Point of
l
Transportation Shipment
G by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Uii Permit Issued to n � Registration Number
Name of Funeral Home ,/�/1 i llr- 1-1,L yz / yy_ c 9 i i 7
Address
Lfi,33-7 aSV-cde 5o Ad/a t-) is/ _k? Ay/rzgi ,
Ro Name of Funeral Firm Making.Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
i
w
Permission is herebyy granted to dispose of the human remains described above as in i ated.
s Date Issued 6,1 %/4c Registrar of Vital Statistics' ( 2
l 111 (signatur )
pil District Number T Place n Ii)i,) -)f /,di,tri I a —
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition 7 i Snt Place of Disposition CV c,.r drs.,i.
(address)
tii
CC (section) n got number) (grave number)
• Name of Sexton or Person in Charge of Premises L/ °.I` L jL'V47ivi
(plejse printt)r,��, A
• Signature4 Title G ��" ' "1
(over)
DOH-1555 (02/2004)