Richards, Paul tart
`'JU 7
NEW YORK STATE DEPARTMENT OF HEALTH �7
>. Burial - Transit Permit
Vital Records Section
Name First /') tMiddle Qd+Last net
y j
_ Date of Death Age If Veteran of U.S. Armed Forces,
Z J? War or Dates -
zr Plac- -th Hospit Institutio? r
t City Tow . Village t) i�J.S / ' Street Address t�J Ovtitit_ ,J C 6:.Q i*
ra Mann- of Death(�Natural Cause Accide Homicide Q Suicide Undetermined D Pending
'�� Circumstances Investigation
W Medical Certifier Name Title
ill K3S ell,A) TO C'O (-6-r— ill
Address ( �/
Deat - -cate Filed, ( District Nt mber S 4 SRegister mber
Ci , Town Village 0 ebr3.t-S k(p t.p
❑Burial Datej Cemetery or rematory ti
- Entombment l 2!/ 9 /( l r,)c" j
Address
Cremation 0G
Date Place Removed
ZI Removal and/or Held
and/or Address
Hold
0 Date Point of
Q Transportation Shipment
614, by Common Destination
Carrier
Q Disinterment Date Cemetery Address
-
El Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home Maxi(-,t-f8 b. enter Ft:,'zP.r .t ,Ho,, () t t 30
Address
S La4GNefi+k S+fet t Qoec r j, ive. ~ .:r L_la231-1
Name of Funeral Firm Making Disposition or to Whom 1
Remains are Shipped, If Other than Above
a Address
ft
111
fit,, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12-I ci-ao I Registrar of Vital Statistics -- - &c..Q Q��
(signature)
District Number Ski Si Place DU e Q (Is 60/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
MiDate of Disposition J 2 jzo//(� Place of Disposition ;�. U; ,,J C(?yyy� .4,
2 (address)
tLi
to
(section) (lot number) (grave number)
0 Name of Sexton r Perso in Charge of Premises - w/IL,.✓t 6 m-acamke.
Z (please print)
Signature ,di" Title e tee-m6. -'
(over)
DOH-1555 (02/2004)