Rocker Jr, William • }
NEW YORK STATE DEPARTMENT OF HEALTH tiltl g
. Vital Records Section - Burial.- Transit Permit
Name First r 1` I l �� Mid�l� Las �G ireA �� Sexes
Date of.Death ✓/ Age If Veteran of'U.S. Armed Forces,
6!l q. ago( & 7,., War or Dates
- 14 Place of Death Hospital, Institution or
VTown or Village £ �..45 -S1ir- Street AddressC �"<<� i.cner of Death Natural Cause Accident Homicide Suicide Undetermined /0 Pending
9
U Circumstances Investigation
ill Medical Certifier Aame, CO ' t— Title
N_; -Gc.�5y5r Mb
Address
C.R,w`',. Gti G fr� ��� "Iv i� 6L -F�ur, I\1`(
"` e-- h Certificate Filed/ District�iumber - _ Register Number
;:.Town or Village C.LtiA- -f[.1� S 6 o L `3tD,
Oi ■Burial Date Go .--a (01,0(6
t6 Cemetery or Crematory
❑Er�torrbment lilt V7e44 6t—`-j ,
s,,,,3 Address / �
®Cremation • C.l. ns b," ���%r'�--
i°''] Date V / • Place Removed
❑Removal and/or Held
and/or Address
i:i Hold
0 Date Point of
tr0 Transportation . Shipment
Q by Common Destination
Carrier
3❑Disinterment Date Cemetery Address
•
❑Reinterment Date Cemetery Address
.
Permit Issued to �- Registration Number
Name of Funeral Ho . .S ,v..,re_ I ;.t,‘,r.u\ ki--,.c, 4,9o(Dr-fs
Address
3er^`4 /mute) �,-.. (-\ 1 /? 1‹'�.)__
. Name of Funeral Firm Making Disposition or to Whom
}-''j Remains are Shipped, If Other than Above
2 Address •
te.
U.'
" Permission is hereby granted to dispose of the human remains doscri nd abov s in ' ed.
Date Issued �a,�a n/( Registrar of Vital Statistics ?"
6 LG
(signature)
District Number 5'.---6 0/ Place ‘z.d,tt'/'o I Li' )
,V r
:::„::i:.
,„„i:::,
i'`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
10 Date of Disposition/,-Z/-/(o Place of Disposition P, Q a
2 (address)
Q
4Z (section) (lot number) (grave number)
IIName of Sexton erso Charge of Premises L Mast bo.,-n
Z (please print)
1 Signature Title C-ce-mva "f'
(over)
DOH-1555 (02/2004) •