Frey, Roland r
NEW YORK STATE DEPARTMENT OF HEALTH N
Vital Records Section Burial - Transit
' Permit
s
Nam First a Middle � Last `Sex ,
Date of Death A e , If Veteran of .S. Armedt"F rces, ,,1�1
1-9 ) l War or Dates �.?�- �.t�9 L.Q &_t
Place ath Hospital, Instituticfn or
Z City Town r Village +4 Street Address Ina 78 P /e'- �h// /a
> : Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined El Pending
LEI Circumstances Investigation
W Medical Ce` i r la Title
Ct
, 0 ,
A ss
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Death Certificate Filed 1 die ��Di�tr c Number Register Number
Cit ow�or Village ' 1 (.4._ 1.� ��(,
..:N El Burial Date /� C etery or CrematAry
❑Entombment , -I '+ I L/�AD (%Ii2./Y-A--/-15 -/
Addres
Cremation (,t,W7u 24 ttA,V
Date PI�Removed
❑Removal and/or Held
.... and/or Address
H Hold
fa
o Date Point of
i Transportation Shipment
t�3
0 by Common Destination
im Carrier
Disinterment Date Cemetery Address
ID Reinterment Date Cemetery Address
Permit Issued to //f� Registration Number
Name of Funeral Home -��c i�X C. , Ofei/!
111 Address
44-eiy,LA A t , 4 A A c AJ d lam, �.7f0y6'
Ei Name of Funeral Firm Making Disposition or to Whom 3
Remains are Shipped, If Other than Above
Address
CC
la
,:`: Permission is hereby granted to dispose of the human remajns described above as)indicated. .
e I itDate Issued I -q- / I Registrar of Vital Statistics .7 `mot.. i( 6, ,,,,,: yt42l
(signature)
District Number 4-5JS Place—Foy wa
decedent identified above were did os of in accordance with this permit on:
" I certify that the remains of the p
LEI Date of Disposition ij) iuiv,it Place of Disposition irdL.) (r cv tatit"-
2 (address)
w
CO
CC (section) Xs,
(lot number) (grave number)
0 Name of Sexton or Person in Charg of Premises � r ��'�^��
(p ase print)
gi Signature A Title MemIcTo(2-
(over)
DOH-1555 (02/2004)