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Robinson, Mary It NEW YORK STATE DEPARTMENT OF HEALTH 4 %i Vital Records Section Burial - Transit Permit Name First Middle, La Sex Itnar� K obihsoi\ 1- Date of Death Age t d If Veteran of U.S. Armed Forces, 01 / 5/ O► CC) V War or Dates — ;- Place f Death -, Hospital, Institution or 'l , i 1 N to rS �I� p LiGivv�cl�� it! Ci , Town r Village �--�C: h .� CO Street Address i U �e� Vr� t-- a Ma 'o Death[4]Natural C se Accident Homicide Suicide Undetermined Pending t ❑Circumstances ❑Investigation jj Medical Certifier Name Title 1 I I i c > r ct cicrrh ; r 1J 310 (,if©o d 5 & 0 caPkv, ska. N `f I I S- 1 Death Certificate Filed District Number Register Number ow City, or Village S C\A0. i 1- coke. !1 (pi ❑Burial Date Cem tery or C em � atory / ❑Entombment 01 p-2/ 01 (to Fa rye, V i-t;tN r t°W1 q. r Address a Cremation a�� { R( Q V)5 .bt.r , \I Date Place Removed Z Removal and/or Held 2 and/or M Address Cl) Hold O Date Point of i 0 Transportation Shipment O by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address K. Permit Issued to � � � Registration Number P"A Name of Funeral Home 1.8 , K -, )�r 1', ", d 107 3 Address /30 6)0161 3-- . sJ 6 tek F I Is N) y Id aO 3 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above 2 Address 2 iti Permission is he eby ranted to dispose of the human remains described above as indicated. Date Issued Registrar of Vital Statistics C (signature District Number ,--/g f Place 0110 /c)r, ti'1 h t',_ V r, y, I,5.,/ A, Y f 2/ z-' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 ILI Date of Disposition ✓-/11--DIG' Place of Disposition p,nt,Vic�) fc 'c or) 2 (address) I T cc (section) _ (lot number) (grave number) 0• Name of Sexton or Person in Charge of Premises -• ,, , T c,rMe y Si.►-. i-ts 2 t (please print) • Signature s �,; !_ . Title off-rvicr10 f- /, (over) DOH-1555 (02/2004)