Skinner, Royce 10
,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First;i Middlej/ Last ) , ,ier Sex
Date of Death ( /�//� Age If Veteran of U.S. Armed Forces,
,/ War or Dates !(�
PI ce of Death / Hospital, Institution /i / 2
r City Town or Village j /41,A Street Address , 16 ;7y/ / cat/
Manner of Deatltj Natural Cause❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
`''��'' Circumstances Investigation
W Medical Certifier Name _ Title
n r►,1'i i l � z).
Address fc4,0t/ e J I/I4 �.
101 fad
Death Certificate Filed // District Number /Q Register Number
cZCi1 Town or Village �¢N�i
/
❑Burial Date d(/o s�/z metery or Crematory
s / "a 4/iC4,_,67c �6/`7/
['Entombment Address— .
El-Cremation c'e v 44-y, /L/ 1 2 9a L1
Date Place Removed
Z ❑Removal and/or Held
and/or
M Address
t Hold
O Date Point of
Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /2 5 - X-7Crc.//i��"" D/// 7
Address �^
Name of Funeral Firm Making Disposition or to Whom
1.0ii Remains are Shipped, If Other than Above
2 Address •
#r _-
ILI
Permission is hereby ranted to dispose of the human remains es abed'abldve a . dicated.
Date Issued d I/67/ X:i_____,(„:...::•--4 Registrar of Vital Statistics - r.
(signature)
District Number Jo, Place A/4, ,, .74c.?—V,/ / ' iy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu Date of Disposition /-g--/6 Place of Disposition / `hc Li 1- ) 1 4/a,;
2 (address)
Lu
Ill
CC (section) (lot number) (grave number)
ti Name of Sextonor Perso in Charge of Premises �� %� �� �
2 (please print)
Signature j Ai., Title 61 f--(Lyra 4,le; '
(over)
DOH-1555 (02/2004)