VanSise, Robert NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sr
n —
R0a� � 2 I-Is U� .) Siser /Y L.-
Date of Deal I Age If Veteran of U.S. Armed Forces,
//Z9// / 1 cp ii y rc..S War or Dates 1/1/ -y(o
- Place of Beath / Hospital, Institution or -
CILI ity, �-r
own r Village QU i s;.0 Q U n, Street Address 9 �1 g e ts2 U AL i•d er
D Manner of Death Natural Cause A cident Homicide 0 Suicide Undetermined Pending
W Circumstances Investigation
tyii Medical Certifier Name j� Title
a D 6>� i\ts)91-/
Address
3'76? .t/c9:,,) S- . 1i isusf A / Z� -
Death i icate Filed ' Di ict N er 'Regi ter Number
City, owr_f r Village a u , , -Q District f 0
❑Burial Date Cemetery Cremator
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Entombment �`3 /
Address �
Cremation Q V '61-. !C ^
Date I Place Removed -
Za Removal and/or Held
and/or Address ' •
r
A Hold
0 Date Point of
ftQ Transportation , Shipment
a by Common Destination
Carrier
Q Disinterment Date ( Cemetery Address
11.
Q Reinterment Date I Cemetery Address
Permit Issued to , Registration Number
Name of Funeral Home tAckynut d , .6cA.ker- Fier I o C i i t-i ci
J Address --� ----_
11 1`a-kyQ lii? S l. , a .C_nS ir�f , ti2 v_s `/or L 12 si0,--\
Name of Funeral Firm Making Disposition or to Whom
#,: Remains are Shipped, If Other than Above —
2 Address
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Permission is h reby granted to dispose of the human remains described ove as indicated.
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Date Issued 1 fi'a 1 Ja.Du Registrar of Vital Statistics '� Q , 1) ILA
(signature)
District Number Place ( L9 9-r-&b.
-
I certify that the remains of the decedent identified abov ere disposed of in rdaAce with this permit on:
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ILI Date of Disposition fe 3l l vi 1 Place of Disposition l�r 11 p t O a'(U r t° .
(address)
W
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LC (section) j (lot numb (grave number)
her S} P11 r 'IN'
Ca• Name of Sexton or Per n in Charge a remises p
(please print)
14 Signature Title CW:d11 O'iL-
• (over)
DOH-1555 (02/2004)