Swinton, Robert NEW YORK STATE DEPARTMENT OF , \LTH€ A 16
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex
ccB d 7- ,�. S l v // /Ton/ /2//9-4. -'
Date of DeathAg If Veteran of U.S. Armed Forces,
A -- V c 0// ov.7y,9s War or Dates ) 43_ i y�
• Place eath a Hospital, Institution or
City, t ow r Village e///J7.- 1)11'.I L Street Address 9'��9 ,S T/qj-� R7 2
Manner of Death Ea Natural Cause Accident 0 Homicide Suicide Undetermined Pending
ILI �I Circumstances Investigation
Medical Certifier Name Title
0 -30h4V S"7-ote-r -/ 0Ed2G rn13
Address
`e2.2 C5W R K s7 6.4 I S' /%gx 4 S' ,4/(
Deat icate Filed District Number `� Register Number
€< Ci Tow r Village ee/,t J 7-E# LJ --6-26--
'><❑Burial Date e� Cemeteryor Crematory
❑Entombment c0^ �- o� C l/ 67/ EJ6LC/ G'gO '4)72,17`O R1 a/Y1
Address ./.9
d'4
;;:;, �'Cremation cir4e , 'Jt/S'03C/ 'y N l ,
Date Place Removed
❑Removal and/or Held
`
and/Holdor Address
=
t0
O Date Point of
%4 ElTransportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /77q g p A/!U4/A R AL iirri72E
cr//-*6
»< Addres
6'o,c8o x 77 pae�7- A/A/ #y, ,/. ?d ?
gi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
0
Ili
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ��� // Registrar of Vital Statistics cg. -¢ -�
(signature)
District Number. — Place ( i%//7 g,gz i ivy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI• Date of Disposition 2..-7Y-ti Place of Disposition P►tit lixlw Livret.r;v+—
2 (address)
Lu
CA
1X (section) (lot number (grave number)
0
Name of Sexton or Person in Cha a of Premises r,4,4- aArk'
eZ (please print)
(14L
Signature Title Cit?(Ikt-4'r^.-
(over)
DOH-1555 (02/2004)