Stevens, Robert J NEW YORK STATE DEPARTMENT OF HEALTH ' 4 7
Vital Records Section Burial - Transit Permit
Name irs Middle Last Sex
Ndbei-r L S retie,uls i/i
Date of Death Age If Veteran of U.S. Armed Forces,
/1 / 9— . '-0�� �a- War or Dates Ala
:.1: Place of Death Hospital, Institution or
j City, Town or Village /t�Co Ai de .. N
Street Address eNi i c
' tin,®em ���(iA
la
s l .src / Gky.�.
ci Manner of Death. atural Cause [�a Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
lit Circumstances Investigation
til
Liu Medical Certi#it,r Name Title
0 r- \
Vc Qdd� \ \ 4\t CO
1 ��J 1` �
Death Certificate Filed District Nurvib r Register Number
;« City, Town or Village ( CA y1 Pam, -S Y0 ��
El Burial Date Cemp$ery or Qrematoory -�--
❑Entombment ��e a ew 64-e.",p roar
Addresj�;�
Eigaremation laYO�,IUS t t) A-Jr
Date Place Removed
Z Removal and/or Held
and/or
i_ Address
toHold
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
Oi
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to r�/J/ / Registration Number
'> Name Funeral Home tt)/ --�. L , k€ fwera/ Wov-e_ ao-�i7
Addre /
iliiH Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ir
tL
Permission is he eby ranted to dispose of the human remain c 'bed ab7 as in.i ated.
Date Issued \\ \-1 \�p Registrar of Vital Statistics
(signatur
District Number �/Sy//R Place cA .p roI
,:,,]::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
p )1 ( coDisposition /2//1.SZ IAQt1ll� Date of Dis osition �� Place of ytsvn..,,fo:) )1,1►-‘_.
2 (address)
ta
#C (section) (lot number) r (grave number)
n
Name of Se •n or Person in Charge of Premises hcAr1 i��+�)ac-.,,r a ,-_
(pl ase print)
OA
Signature ALIPEZA) TitleCut
(over)
DOH-1555 (02/2004)